HomeMy WebLinkAboutBLDG-20-005034 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
w,--Tfis, CITY it ctY' t► MA DATE 3 "-I — .26 2.0 PERMIT# Cb��,�
JOBSITE ADDRESS ! TAS °� ) Q,� Q —, OWNER'S NAME i`A C. OC 14kt
GOWNER ADDRESS S fA,th TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL e
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ICJ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--+ c 2
6�I� 1 3 4 5 6 7 9 10 'I'I 12 '13 14
BOILER —�
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER --�
DRYER I
FIREPLACE
FRYOLATOR
FURNACE
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
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Cl. ES ra. NO 7 D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW O`%D
LIABILITY INSURANCE POLICY Tr. OTHER TYPE INDEMNITY ❑ o D KI\R 11 2020
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required ti fr9 ,RTM ENT
Massachusetts General Laws,and that my signature on this permit application waives this requirement. -L.
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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 comp€ianc wi h all Pgrti ent provision of the
Nz, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %, / i
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PLUMBER-GASFITTER NAME LICENSE# ) 5 u)I SIGNATURE
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MP !P MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑## LLC❑#
COMPANY NAME s NW\ Yj i V\y ADDRESS 1774 W cal (44(2 t1
CITY .77 . Y cY Y•t�,of in STATE i'�1G ZIP 67l L 7' TEL �U /,7;7 3 6 7
FAX CELL SOcifl r' EMAIL i cort ei o de 1)3 eci, 1 G,, ( .C c' tyk
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FIThiAL INSPECTION[O <
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ []
FEE: $ PERMIT#
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