Loading...
HomeMy WebLinkAboutBLDG-17-002756 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ��S'w.c .�� MA DATE ��Z1//6 PERMIT# b nC, JOBSITE ADDRESS /5 s c�y OWNERS NAME ^��'^+-- Go OWNER ADDRESS ' £ S /liLL� U`�� TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[k/ PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO APPLIANCES FLOORS--# BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 I 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER _ I FIREPLACE !/ FRYDLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER I ROOF TOP UNIT TEST _ UNIT HEATER UNVENTED ROOM HEATER j 'i 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 hIC3 ❑ 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 a rate to the best of my r wledge and that all plumbing work and installations performed under the permit issued for this application will be in compliant with all Pertinen rovis' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME e;..� e , s L ��,,, � LICENSE#2,0221 SIGNATURE MP ❑ MGF❑ JP JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP El# LLC❑# COMPANY NAME ADDRESS ? ll IzCI; CITY /77c;f---/,, STATE ZIP C 6 Ss--- TEL 7 y-- )-G t//O FAX CELL EMAIL e ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 6/1=-'" q/1-�j .i'� L '(es ado (1//g ✓ /� THIS APPLICATION SERVES AS THE PERMIT ❑ FEE: $ PERMIT# PLAN REVIEW NOTES