HomeMy WebLinkAboutBLDG-17-006843 ` - ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
:k,7 CITY i�(?-/Y7ani MA DATE c25',3412' - /7 PERMIT# , 4i9b-)7-lfcilOYYi�
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JOBSITE ADDRESS Cg /�/JPr2/1Z/G OWNER'S NAME riCt IC 'v
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:[RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOle'r
APPLIANCES:I FLOORS BSM 1 2 3 4 5 6 7 5 9 10 11 12 '13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
_
DIRECT VENT HEATER
DRYER '
I
FIREPLACE V
FRYOLATOR _
FURNACE
- _ , 1
GENERATOR. \
GRILLE t
INFRARED HEATER I
LABORATORY COCKS '
MAKEUP AIR UNIT I
OVEN ii1
POOL HEATER
ROOM/SPACE HEATER I
ROOF TOP UNIT
TEST _ t'✓ 6. ,--G e._
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES MI6 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAC .BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
- Massachus-efts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT J
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
`k- and that all plumbing work and installations performed under the permit issued for this application will be in co . nce 'h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMEER-GASFITTER NAMEPv I6600(3 LICENSE#, ----'('0 4 SIGNAT -
MP ❑ MGF❑ JP ❑ JGF�PGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME ,,� ,g-ADDRESS 1 7 �/f C/2'
CITY I .4IOi/tT (-. STATE ` Vi ZIP 0 ;e0 ' TEL
FAX CELL EMAIL IMF S f 4f6 b F � !T£/�T c;
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION MOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: $ PERMIT it
7J7 / PLAN REVIEW NOTES