HomeMy WebLinkAboutBLDG-16-006714 MASSACHUSETTS UNIFORM APPLICATION FOR A.PERMIT TO PERFORM GAS FITTING WORK
rtal-
v '-', MA DATE O /06 PERMIT#h`R/16 67/e-
JOBSITE ADDRESS /05 et) C c- vv.. OWNER'S NAME 6/e-1..- s( t›...
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO[ �
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER - I
BOOSTER
CONVERSION BURNER _ !
COOK STOVE
DIRECT VENT HEATER _ I
DRYER j
FIREPLACE
FRYOLA f OR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _ 1
OVEN l'
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENITED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES h€t� ❑
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{have submitted or entered regarding this application are true and acc to to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will he in compliance all Pertinent provision of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Gl e.- - - LICENSE#Zr/9C)-1 SIGNATURE
MP❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME /— ADDRESS 2.0 V C �c ..�s EC/4
CITY //c-r-L4-c, L STATE / 4 ZIP 0 ZG 95— TEL )7 �c�.9 G Y//'
FAX CELL EMAIL
ROUGH GAS INSPECTION NOT STHIS PAGE FOR INSPECTOR USE ONLY FINAL.INSPECTION NOTES
A AL al tS 0X LJ2l-{ C%k `4f es No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES