HomeMy WebLinkAboutBLDG-18-002136 �'.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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` 'a,�_ R CITY `ietfrunM --.. M4, DATE 1>f iJItl PERMIT* / 4&--71?'eV2/.
JOBSITE ADDRESS 32 Gc:ty-•4 L\ Nit, OWNER'S NAME wcrut.w —ctl
GOWNER ADDRESS TEL FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,
CLEARLYNEW:❑ RENOVATION: ❑ REPLACEMENT: p PLANS SUBMITTED: YES❑ NO❑
APPLIANCES J, FLOORS 6SM 1 2 3 4 5 6 7 8 9 10 11 12 13 1'
BOILER
BOOSTER
CONVERSION BURNER. 1
COOK STOVE
DIRECT VENT HEATER 1
DRYER __1
FIREPLACE 1
FRYOLATOR
FURNACE
GENERATOR.
GRILLE 1
• INFRARED HEATER I
LABORATORY COCKS I
MAKEUP AIR UNIT
OVEN i
POOL HEATER 1
ROOM/SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER I
OTHER J I
1
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MM..Ch.'142 YES M NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY �o] OTHER TYPE INDEMNITY ❑ BOND [1] 1
• 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.
I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT J
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
`k- 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 S DC-coj-t,t LICENSE#3 t SIGNATURE
MP❑ MGF n JP N JGF❑ LPGI ❑ CORPORATION❑#F PARTNERSHIP❑It LLC❑#i
COMPANY NAME kj-"^Q ""bV ADDRESS °'0. 60'6. 6-1"S—
CITY (0,(_YWIi'�t7,-ti IAA STATE � ZIP 6Zt039 TEL "1�T1-i Z(Z--Z?eb
FAX 1 CELL EMAIL
ilei—
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL IINSPECTIGN NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES