HomeMy WebLinkAboutBLDG-18-006099 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r-11V6w CITY 7Pre'o°�� M?, DATE PERMIT* --o
JOBSITE ADDRESS / 7 13T0ADc + Lirne OWNERS NAME J ' .1\ 012
OWNER ADDRESS I—7 g FAX
RS 'LAoz TEQ`'c-)<;"- FAX
TYPE PRINTOR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ' "❑ R�SIUENTIAL 1:
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES T FLOORS-+ BS1vl 1 2 3 4 5 6 7 6 9 10 11 12 •13 1'
BOILER
BOOSTER j
CONVERSION BURNER _ _
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER
LABORATORY COCKS
, MAKEUP AIR UNIT
OVEN
POOL HEATER 1
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST ,
UNIT HEATER 3311
-i
UNVENTED ROOM HEATER
WATER HEATER
OTHER
. I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MEAL.Ch.142 YES [ NO ❑
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 compli all Pe ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME C-(E6ol.2y LICENSE#.7`y SIGNATURE
MP❑ MGF❑ JP Ex JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC E#
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COMPANY NAME vR-F�`''f t. `l�Crnn6 C vc ee ADDRESS Ali S#'��nl,�� Z�re
CITY b')• px-rno,-I h STATE m ZIP b a6-73 TEL sw)�N--`
FAX CEL451,0T - I"(3 ‘.1EMAIL re.„i fe ro
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES