HomeMy WebLinkAboutBLDG-23-9493 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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� CITY� �J "\ hhr, DATE FERIA IT f; &.iJ6-L3- `1193
JOBSITE ADDRESS l (Ay OWNER'S NAME G-tkr4,o
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
PRINT
❑ RESIDENTIAL
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ N
APPLIANCES FLOORS-I SCM 1 2 3 1 5 6 7 6 9 10 '11 12 13 11%
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _
DRYER
FIREPLACE
FRY OLATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM SPACE HEATER
ROOF TOP UNIT
TEST .
UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER sf
OTHER RC_JV/
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES.h40 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
'1• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a urate to the best of my knowledge
` and that all plumbing work and installations performed under the permit issued for this application will be in compliance h a Pectin , provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME/ 1ock"i C1 A)e;6Uv t't/V) LICENSE# O�J SIGNATU .E
MP ❑ MGF❑ JP ❑ JGF[ LPGI ❑ CORPORATION❑#t ARTNERSHIP❑ LLC❑#
COMPAN 'NAME C0-(tavAd_r ADDRESS ] -6
CITY Olket e 4 STATE44- ZIP TEL - // 2�J
FAX CELL EMAI IC
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑•
❑
FEE: $ PERMIT f
PLAN REVIEW NOTES