HomeMy WebLinkAboutDG-18-007293 `' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Wn WW1" CIT( V A V Va 111 MA DATE 6 "'o'�a ( O PERMIT**/21,-'/e-a)7.115
JOBSITE ADDRESS 1 1 I t19,5 CC, (VI I.I.S C. s OWNERS NAME * S 119 S K r
GOWNER ADDRESS ,5) J EL FAX
TYPEOROCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL IV
PST
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [e PLANS SUBMITTED: YES❑ NO ❑
APPLIANCES 1 FLOORS-h Bslu1 i 1 ? 3 4 5 6 7 8 9 10 'I'I 12 '13 14 I
BOILER
BOOSTER I
CONVERSION BURNER _ _
COOK STOVE I
DIRECT VENT HEATER I
DRYER '
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR I
GRILLE I
INFRARED HEATER
LABORATORY COCKS Ili1j
MAKEUP AIR UNIT / I
OVEN
c \ li
POOL HEATER () 1
ROC>M/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
• 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 1❑
SIGNATURE OF OWNER OR AGENT
•-t-, 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 compile ce with all Pertinent provision of the
LI
Massachusetts State Plumbing Code and Chapter 1 I
42 of the General Laws. E4��} is
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PLUMBER-GASFITTER NAME CENSE# I sa I I SIGNATURE
MP !( MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION t PARTNERSHIP #
❑ LLC❑#
COMPANY NAME �
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V A 1r � 1�t- - P I I.�Vr ��i � ADDRESS (-I `') �.t) i � W lT
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CITY , 1 (:. v- VN DL, 't., STATE 4, ZIP 6)2. L 69 1/ TEL36i1/23735 g'y !
FAX CELL 5 C,� 1O e EMAIL l c-tV taev vt LI_ 1 L 5
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES