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HomeMy WebLinkAboutBLDG-17-003933 I _ I. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fiArVt `=:��, e CIT'( G✓ t�,--7,2Mo.,eTit- Ian?, DATE a-T & PERMIT# %f&'17 (4 �=r pM 1 r O /(4/ G-7.f JOBSITE,ADDRESS ©I �/ �/ �/�1` �0 OWNERS NAME J`, G OWNER ADDRESS TEL FAX T-g--)7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO FL' APPLIANCES 1 FLOORS—F BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER --I BOOSTER CONVERSION BURNER. j I COOK STOVE I DIRECT VENT HEATER j QRYER . FIREPLACE '._ __ .., __.., 1 FRYOLATOR —# i- GT ENERRAATOR f FEB 3--2 2117 GEN GRILLE — --I 07- - -44 tt .l: - - INFF�ARED HEATER `"`" `4,Ir, , I11 ' j I LABORATORY COCKS _— MAKEUP AIR UNIT I OVEN POOL HEATER ROOM/SPACE HEATER I ROOF TOP UNIT TEST t/r UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES t0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG•BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I 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. i CHECK ONE ONLY: OWNER ❑ AGENT ❑ --. SIGNATURE OF OWNER OR AGENT j • I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accuyate-te the best of my knowledge �� and that all plumbing work and installations performed under the permit issued for this application will be in compliance • aLPertinent provision of the i Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Lo PLUMBER-GASFITTER NAM S(Tgl`rir/ E o g£iz f 5 LICENSE#c/041- MP ❑ MGF❑ JP El JGF<PGI ❑ CORPORATION❑# PARTNERSHIP El# LLC❑# COMPANY NAME ADDRESS ( 7 L -K C /0 CITY ' t( ,,t► STATE /4'¢ ZIP TEL S J 6 YIP 9®0 FAX CELL EMAIL aifr ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES fey No THIS APPLICATION SERVES AS THE PERMIT ED [I] 0/C.- /-171- FEE: $ PERMIT#C PLAN REVIEW NOTES c7V5z./