HomeMy WebLinkAboutBLDG-18-003359 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
` CITY YAf f" i MA DATE 12)/o3/ici) PERMIT#N- —/f'- 3 5`l
JOBSITE ADDRESS 3 4 Ca ' S4 OWNERS NAME CAGG; y /t4ZLo
OWNER ADDRESS 3 s4 TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Nr/
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS--4 6SM 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
FIREPLACE
FRYOLATOR
FURNACE 1—
GENERATOR.
i GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
Is-'ô
UNIT HEATER
LINVENTED 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 [1O ❑
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
L I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura' e est of my knowledg
and that all plumbing work and installations performed under the permit issued for this application will be in complianc all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME l V/
Q,C7iLr0�j;ti(/a LICEt'dSE434j9,)-- `N
MP❑ MGF❑ JP [r JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP CI# LLC❑#
COMPANY NAME S !'n Lti✓W1)r 1/Ci c u,V(j ADDRESS /6- #11/-e
CITY � Oa�d { TEL
�1/ti 15 STATE �Q ZIP L
FAX CEL� `LIM°{�c3 EMAIL V I AG1Lti(j,UV��G_,UQ�/1/� -cam
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ []
FEE: $ PERMIT#
PLAN REVIEW NOTES