HomeMy WebLinkAboutBLDG-18-001696 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY V� l G( f✓� Q c l` MP, DATE PERM IT*, /Na I l$ v�/
JOBSITE ADDRESS /6 /T/ r//15 cLLJ OWNERS NAME
OWNER ADDRESS / J rr 5 era rdc2 1)-1 V4 ta-OO TEL FAX
TYPE OR -re) 737 El PAP OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESID N IA
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [0. PLANS SUBMITTED: YES ❑ NO k
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APPLIANCES 4 FLOORS-4 BSIJM 1 2 3 1 5 6 7 5 9 10 11 12 '13 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 sFP
ROOM I SPACE HEATER.
ROOF TOP UNIT CKt1-1 „
jTEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER i 1 Ce �J p /9-L , f -✓�-r
p a r !--1,49 F �.,�t _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOLL Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO\VERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ II
• 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
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. c9.40
PLUMBER-GASFIT-FER NAME 7 i C L c- ('fLICENSE# rU P SIGNATURE
MP ❑ MGF❑ �JP ❑ JGF LPG' ❑ CORPOP 1T ION❑4 PARTNERSHIP❑#1, LLC❑#�:
COMPANY NAME V J �. �� r P �� ADDRESS// '�' 1 Y fe--dIjr--/s L., at
CITY / / V V I (� 0/A J-e/ LGc‘Q STATE ZIP e TEL(p y TEL 27 4 Y70 F7 a Z
FAX CELL EMAIL • -e/' .
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES