HomeMy WebLinkAboutBLDG-17-003143 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY Yiot? LL-T.vPL>g-1 MA DATE (a(4'(/6 PERMIT* U^17 jM
JOBSITE ADDRESS e Se ?<A g (0,A OWNER'S N.AMEnhz-t$T r-(L •6557-
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑�
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS—F BSM 1 2 3 4 5 6 7 8 9 10 'I1 12 '13 1 1'
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR ,
FURNACE I
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
_ _ I
INSURANCE COVERAGE �, �
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NICL.Ch.142 YES IJ'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 ❑ 11
SIGNATURE OF OWNER OR AGENT
s, 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 be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME & -' '—= - tiVV LICENSE It 3?3 SIG
MP ❑ MGF❑ JP LPGI ❑ CORPORATION ❑4 PARTNERSHIP❑# LLC❑#
COMPANY NAME 1JVe _4- }-113 ADDRESS `7j q C 1 Z1t 4Qo
CITY ►6Y12vt_Al t-la STATE �� ZIP 026�i TEL ,08-act&33%5'
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#I
PLAN REVIEW NOTES