HomeMy WebLinkAboutBLD-18-002214 _ 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMfT TO PERFORM GAS FITTING WORK
s 0-� - `���6N CITY j�l`���`�!�- 1�4A DATE �3 ac r�a�� PE€-EMIT# �� �
JOBSITE ADDRESS Lg 61—c,25 C c eZ.- OWNERS NAME �/g-1 �L iO 1
OWNER ADDRESS TEL FAX
TYPE OF OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL EI---
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-F BSlui 1 2 3 4 5 6 7 8 9 10 •I'I 12 13 14
BOILER
BOOSTER
CONVERSION BURNER j f 0 V--
COOK STOVE / 5 ) `
DIRECT VENT HEATER V
DRYER
FIREPLACE L..'" J
FRYOLATOR
FURNACE
________, 0-:::GENERATOR I
GRILLE _ -
INFRARED HEATER /�
LABORATORY COCKS ^ , ,
MAKEUP AIR UNIT (V I
OVEN i
POOL HEATER
ROOM I SPACE HEATER III
ROOF TOP UNIT
TEST - . t _ . ........ -- .
UNIT HEATER 1
UNVENTED ROOM HEATER
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ir-NIC--c❑
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.
s.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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
`— and that all plumbing work and installations performed under the permit issued for this application will be in compli ' ent provision of the
`` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME c,r i1 .ii/ 6 i; LICENSE#c(01/ SIG
MP❑ MGF❑ JP ❑ JGF PGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑
COMPANY NAME ADDRESS (-2 - 4-- C Oir-
CITY PL-`/ai �v4-1-1T STATE/YI ' ZIP aa CO TEL S C) . c�fif c9y'0O
FAX 6FJ.11- EMAIL Cil/(`W sr-r,/KA.66f2TS rj-5.if f%f%.f6.i
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FII IAA INSPECTION i OTEg
Yes No
!1 ' -1 Y/:)777-
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT tt
PLAN REVIEW NOTES
