HomeMy WebLinkAboutBLDG-17-003840 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESH V l./0 0 gays 44um Olhr(d NAME l}"e!O ei
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALPRINT
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CLEARLY NEW:❑ RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 10❑
APPLIANCES--1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM;SPACE HEATER
ROOF TOP UNIT
TEST
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 MGL.Ch.142 YES B1O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG 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 and accurate to the best of my knowledge
3, and that all plumbing work and installations performed under the permit issued for this application will be in oomph: 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p
PLUMBER-C FITTER NAME V� "PO c�—\-c�n O eo — LICENSE#( I 9 lc( SIGNATURE
MP I MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑it LLC❑#!
COMPANY NAME PQ OV rteu'to 9 ADDRESS 2-2- 6
CITY w�J111 S STATE ,AV ZIP o2-65 ci y7,3
FAX CELL EMAIL 2 4 2017
14_
ILDING DEPAf� ��J��
(may"
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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