HomeMy WebLinkAboutBLDG-20-001570 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMFT TO PERFORM GAS FITTING WORK I
% 0x cri-t 195?-?%20/ # aO o " 1
� ,,.—s, CITY Ir�r. DATE P_RMIT.� �d�S 0
JOBSITE ADDRESS S.a P4 i Sam / OWNERS NAME /112/ "- S�
GOWNER ADDRESS TEL 6Y7 999 3(// FAX
•
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL M
PRINT
CLEARLY NEW:'gib RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
i
APPLIANCES FLOORS—F BSM 1 2 3 4 5 6 7 9 10 11 12 •13 14 1
BOILER
BOOSTER I
CONVERSION BURNER I R llI
COOK STOVE I I
I
DIRECT VENT HEATER ill P 8 p �'
DRYER
FIREPLACE t ING ,EPA ►t i
FRYOLATOR
FURNACE
GENERATOR __ MIN
GRILLE _
INFRARED HEATER I
LABORATORY COCKS - I
MAKEUP AIR UNIT I
OVEN I
POOL HEATER
ROOM I SPACE HEATER 1
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I `
OTHER I `�
I
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES jt NO ❑
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 I have submitted or entered regarding this application are true ► ebest of my knowledge
`; and that all plumbing work and installations performed under the permit issued for this application will be in compliance IIPefttnent-provision o_f the
1 Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LE
PLUMBER-GASFITTER NAME, 7T Ptr,,Ii p.6t 2 IT LICENSE#5s(O 4- SIGNATURE
MP ❑ MC-IF❑ JP❑ JGF 5 LPGI ❑ CORPORATION❑#i j PARTNERSHIP❑# LLC❑
COMPANY/� NAME ADDRESS l Z.�e I) r
/�CITY —j"/-14 Oa r STATE,/1/4//` ZIP e9e?36 TEL
FAX CELL EMAIL l/l/[ Q STr ta /20rf&i5 qD►
i'St f6
ROUGH GAS INSPECTION NOTES THISPAGE FOR INSPECTOR G€ USE ONLY FINAL INSPECTION
NOTEg
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑
•
FEE: $ PERMIT(t
PLAN REVIEW NOTES