HomeMy WebLinkAboutBLDG-16-005172 &8A88ACHUSETTSUN1RORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY M A DATE / . []A� pER N|T# 4' m4,-^'- 57 7A
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JO8�TE&DDRESS '� ~ ~~ `'- ' -~ '''^ OWNER'SNAME
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�_� OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE ��COMMERCIAL�� EDUCATIONAL RESIDENTIAL��
PRINT ^� ^�
CLEARLY ��/
NEW:�� RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESD NOD
APPLIANCES-1 FLOORS-~ oGw 1 2 S 4 5 O 7 8 9 10 11 12 13 14
BOILER
BOOSTER |
|
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE ~- |
FRYDLAT0R
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN —
POOL HEATER |
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ROOM!SPACE HEATER '
ROOF TOP UNIT
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TEST w~
UNIT HEATER
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 cf MQL Ch.142 YES PEr'NO
||F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BYCMECK|NGTHEAPPROPR|ATEBOXB5L0N
LIABILITY INSURANCE POLICY Rj OTHER TYPE INDEMNITY D BOND Fl
OWNER'S INSURANCE WAIVER: |am aware that the licensee dpaa not have the insurance oovona0o required by Chapter 142 of the
Massachusetts Gonomi Laws,and that mysignature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F� AGENT S|�NATUREOFOVVNERORAGENT ��
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 an Plumbing work and installations performed under the permit|aovad for this opp|ioounn will be in n
Massachusetts State Plumbing Code and Chapter 14um the General Laws. -''~^
PLUMBER'GASF!TTER NAM B�-��/ry��' �/-`��/^ ~-' 7 LICENSE# �^�./
MP El M8F[:1 JP El JGFP"LPG| El CORPORATION D# PARTNERSHIP 0# LLC #
COMPANY NAME ADDRESS ( -) L-"?-^�r '0/y
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CITY /-/�L'/1«0L/ ' `+ STATE 417 zip 0-3 36- �D TEL �� c}9^�
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
0if" 04 die ✓ J Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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