HomeMy WebLinkAboutBLDG-17-03225 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CIT`( So. yG-� c ✓ MA DATE /Z// PERMIT# ✓✓ �1 17 Oa✓°�"'�
JOBSITE ADDRESS is v e OWNERS NAME VeC a y... L L P
OWNER ADDRESS Z 0 �l L-..` �c fi v Z TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL� EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: EPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO
APPLIANCES FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 •11 12 13 I 1'
BOILER
BOOSTER —�
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE '•
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN J�
POOL HEATER !
ROOM/SPACE HEATER i
ROOF TOP UNIT
TEST
UNIT HEATER
(INVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES [ ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliant h all Pertinent provisio ie 1
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (-7
PLUMBER-GASFITTER NAME G r e,, S 4 LICENSE#?-0Y SIGNATURE
MP ❑ MGF❑ JP —1F❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME ADDRESS ZG U eL-cc1,,,i- H ; Rd
CITY ��w i c. STATE/ ZIP C 6 �rj' TEL 22 y -O
FAX CELL EMAIL
414
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTjON NOTES
)11i 6/75 (7/-t
Yes No
/6-Ao THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT/
PLAIN REVIEW NOTES