HomeMy WebLinkAboutBLDG-17-001998 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
4r".`_,.. MA DATE f /i PERMIT t /01/)(r-/7-OO f?9
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JOBSITE ADDRESS Y • OWNERS NAME LI.54-3" n s ov.\
GOWNER ADDRESS //'Yq iii 15 TEL FAX
TYPE OR
T OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[E--"—
PRIN
CLEARLY LY NEW:❑ RENOVATION: ❑ REPLACEMENT: [y` PLANS SUBMITTED: YES❑ NO
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APPLIANCES 1 FLOORS--F BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 I 14 I
BOILER -
BOOSTER
CONVERSION BURNER,
COOK STOVE _
DIRECT VENT HEATER l
DRYER
FIREPLACE
FRYOLATOR
FURNACE-, -
C I -GENERATOR
W 1GRILLE ' '
> INFRARED1REA'TER I
LABORAT*(qocKs
MAKEUP File UhlIT !
OVEN
v POOL HEATER 1 i
uj I ROOM I SPACEIHEATER I
LROO.F.TOR-IJNI�i •
TEST €
UNIT HEATER- _
UNVENTED ROOM HEATER
WATER HEATER <Jg0 O PA _/__.
OTHER Q t Q (,,✓/lt _
I
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INSURANCE COVERAGE I
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MIGL.Ch.142 YES O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY II.'"--- 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.
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al I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT i
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
z and that all plumbing work and installations per formed under the permit issued for this application will be in compliance with all Pertinent provision of the
�, , Massachusetts State Plumbing Code and Chapter of the General Laws. ^
PLUMBER-GASFITTER NAME f1 i c61 c ec. Alp/ k LICENSE# / (Y) SIGNATURE �
MP❑ MGF❑ JP b—J[ JGF❑ LPGI ❑ CORPORATION ❑# pfb P PARTNERSHIP❑# LLC❑#
COMPANY NAME c rr cfLe P "--- i"t'
ci ADDRESS / " Yjd z —C -G/`Z
CITY ° q r"/27 d C.)21 STATE 6144i. ZIP O 2461 TEL 7r 7fO ,/8.z
FAX CELL EMAIL nJ.�✓"_ ti3 ri JP 4 /L•C
„jG� I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No C)J t 'C /0/f4�/G
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#I
PLAN REVIEW NOTES