HomeMy WebLinkAboutBLDG-18-002213 Sri;,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY ����'7�-�5�.. MA DATE l/? /? PERMIT# �(7- >L3
JOBSITE ADDRESS 0 7 -'1,41-6 07Z, VZ OWNERS NAME V , -1LY l F,
OWNER ADDRESS TEL FAX
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TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL cV
PIT
CLEARLYNEW:RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-F BSlui 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —�
BOOSTER —�
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE ✓
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER I
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN i
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST -
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 NIGL.Ch.142 YES IPIO ❑
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 INSURAI'4CE 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 ❑ j
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 and accurate to the best of my knowledge
- and that all plumbing work and installations performed under the permit issued for this application will he in compliance wi all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME S ) /7$c"V fZ(,i (273 LICENSE# �ay' SIG
MP❑ MGF❑ JP❑ JGF L1y LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#I:
COMPANY NAME ADDRESS f L r O'L
CITY A 7 91 L}- STATEM ZIP D c?'- °`2 TEL
FAX CELL EMAIL r4/4. Srf"off✓)2104f2
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLYEllalAL INSPECTION 1 OTE
Yes Na
THIS APPLICATION SERVES AS T PERMIT ❑ ❑
PEE: $ PERMIT t
PLAN REVIEW NOTES
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