HomeMy WebLinkAboutBLDG-18-006656 . ' K8ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
JOBSITE ADDRESS �17 OWNER'S NAME
OWNER ADDRESS TEL �� ��—/9 FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL�l EDUCATIONAL �� RES|OENT|AL��
PRINT ^� ^� ��
CLEARLY
NEVV:F RENOVATION: F-1 REPLACEMENT: PLANS SUBMITTED: YES9- N0Fl
APPLIANCES-1 FLOORS-^ o8w 1 2 3 4 5 h 7 8 9 10 11 12 13 14 /
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER |
|
FIREPLACE - ---�
FRY0LATOR
FURNACE
` GENERATOR
GRILLE �
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN '
POOL HEATER
ROOM/SPACE HEATER '
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ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER 1
WATER HEATER
OTHER |
| |
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INSURANCE COVERAGE
X
| |have a current|iabi|Uv insurance policy nr its substantial equivalent which meets the requirements nyMGL.Ch.i43 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
~ LIABILITY INSURANCE POLICY N OTHER TYPE INDEMNITY 71 BOND F�
, OWNER'S INSURANCE WAIVER:I arn aware that the ficensee 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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CHECK ONE ONLY: OWNER [] AGENT
SIGNATURE OF OWNER ORAGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate tn the best ofmyknowledge
and that all plumbing work and installations performed Linder the permit issued for this application wii|hein compliance with all Pertinent provision ofthe
Massachusetts State Plumbing Cou o,1*�cxmoSonam|�owm. .
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PLUMB ER'GASF!TTERNAME / «| «���/ ` � �.��� [7x�~�/ LICENSE `~—�- 8|S�x�U��-/ ~~`--'��-
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WP17 M8FE-1 JPE9 JGFEl LPG| [I
COMPANY NAME k~ `~{_/��' /` / ~S4 / / ADDRESS
CITY ���� �� / / STATE ZIP /~� TEL
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FAX CELL EMAIL
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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# T 6,0
PLAN REVIEW NOTES