Loading...
HomeMy WebLinkAboutBLDG-18-001750 �`� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 ,tl ' It :t,�._.6 CITY MA DATE PERMIT t- ei0 1 (-00 I'76 d ,,, �s_� JOBSITE ADDRESS OM ER'S NAME /eigilL___ GGWNER.ADDRESS TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL©f PRINT CLEARLY ' NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES. FLOORS—F BSM 1, 2 3 1 5 6 8 9 10 11 12 13 14 BOILER Ille ■ ---I BOOSTER CONVERSION BURNER _ COOK STOVE =- ; DIRECT VENT HEATER ❑ DRYER FIREPLACE 11 ill ' FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER ❑ ❑ ❑ . LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER. 111111 ' �ROOF TOP UNIT MI __ 0 , j TEST - . UNIT HEATER i i % UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MEAL.Oh.142 YES ❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE EY 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: OW ❑ 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 a 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 i e 'Went provision of the ` Massachusetts State Plumbing Code and Chapter*142 of the General Laws. ' PLUMBER- SFITTER N 4E LICENSE v5y'q4 SIGNATUREMP I MGF JP JGF LPGI ❑ CORPORr1TION❑ I PARTNERSHIP❑ t LLC❑# COMPANY NAME f 6,9 12:7- P ii ADDRESS 2 ,t itirrC V t( �� CITY Y* 1L4 STATE LIP 62 6 TEL FAX CELL 50 5/5a59civii ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY IaINAi,INSPECTION NOTES Yes No /n�,/�¢, VF� THIS APPLICATION SERVES AS THEPERMIT ❑ ❑ U ?"71-.°'/7? FEE: $ PERMIT t6 PLAN REVIEW NOTES 4'