HomeMy WebLinkAboutBLDG-17-006108 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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G 6, CITY / ; '—/ MA DATE oZJ 7- ,y�l 0f7 PERMIT# /3�I)/r-/1-0(96/ '
JOBSITE ADDRESS C 7f J*y /'ayr /Z,"" OWNERS NAME (f'5/-1
TEl / ""' a-7 FAX OWNER ADDRESS
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TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO E I
APPLIANCES 1 FLOORS-+ q 27 0 h
KW 113 4 5 6 t. 9 1i1 'I•I 12 13 I 1-
BOILER
BOOSTER
CONVERSION BURNER _
COOK STOVE _
DIRECT VENT HEATER
DRYER
FIREPLACEtZr
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER 1441 23 - I
LABORATORY COCKS
MAKEUP AIR UNIT ("ik
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST - -
UNIT HEATER
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 MGL.Ch.142 YES id
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 j
71_, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance a11iP2rtieent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ,SIrre t,'-' r2(94 f21 5 LICENSE ei o SIGNATURE
MP ❑ MGF❑ JP ❑ JGF[r�CPGI El CORPORATION❑# PARTNERSHIP❑# LLC❑#I
COMPANY NAME ADDRESS 17 L1 ,0/7
CITY rL y �nT STATE M� ZIP TEL
TEL � ‘V r°9av
FAX CELL EMAIL rove-0 L` /2v2r P 4�s
ROUGH GAS INSPECTION INO'TES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
C / A
ff THIS APPLICATION SERVES AS THE PERMIT •
❑ ❑
FEE: $ PERMIT#
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