HomeMy WebLinkAboutBLDG-18-006390 d Fc-(-- luxorv,17
.17›". MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`' 1.- CITY thAf w.v.. IVIA DATE Shiljg PERMIT 4 /� �� 4D
JOBSITE ADDRESS Z• Nc c't..ys t v". OWNERS NAME c--r-s- C-c..Cc,..., -i�ci
OWNER ADDRESS TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL 11.------
CLEARLYNEW:❑ RENOVATION: EPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO®-''I
APPLIANCES T FLOORS-, BSM 1 2 3 4 5 6 7 5 9 10 11 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _ I
DRYER
FIREPLACE
1
FRYOLATOR
FURNACE '
GENERATOR
GRILLE I
INFRARED HEATER I
LABORATORY COCKS I
i MAKEUP AIR UNIT I
i OVEN
POOL HEATER 1 7., is c \ # t l
ROOM/SPACE HEATER I
ROOF TOP UNIT
TEST - U.
UNIT HEATER C. 4- )
UNVENTED ROOM HEATER /, I
WATER HEATER
OTHER l
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NICL.Ch.142 YES ' NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V- OTHER TYPE INDEMNITY ❑ BOND ❑
1
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.
I
CHECK ONE ONLY: OWNER ❑ AGENT Q
SIGNATURE OF OWNER OR AGENT I
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
3- !that all plumbing work and installations performed under the permit issued for this application will be in compliance , ' all Pertinent provisio the I
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,
PLUMBER-GASFITTER NAME G k._ . '�� 5 L r _ C.-� LICENSE#?I:4 2j SIGNATURE
MP ❑ MGF❑ JP 3-di�GF❑ LPGI ❑ CORPORATION❑#>: PARTNERSHIP❑# LLC❑# I
COMPANY NAME ADDRESS ZO 1)vx-..c___v L-5 F c'`/ la el
CITY h j4--r-LAI c--L.- STATE /(74 ZIP 0 z6 `9'5 TEL 727- ,-a 9/O
1
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
1/P6 67 ° C!� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
,c7�jQ FEE: $ PERMIT#
PLAN REVIEW NOTES
