HomeMy WebLinkAboutBLDG-17-003131 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ul`'q1.1 CITY Y�11�"I U �� �`� MA DATE j MIT* G�C� 7 ��j/ /
JOBSITE ADDRESS /� V 6 " itY6NER., N. ME
GOWNER ADDRESS . "fvl EL; FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDU, '- td� a V '-- EI ITIAL IN--
PRINT
CLEARLY
NEW: ❑ RENOVATION: ❑ REPLACEMENT: DEC P AI SUBMITTED: YES❑ NO ElI
02 2016
APPLIANCES 1 FLOORS--h BSM 1 2 3 4 llC], ��E pARI-._ s 9 10 11 12 '13 14
BOILER ...ys— MENT
BOOSTER '"
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER i
DRYER •
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE 1
INFRARED HEATER I
LABORATORY COCKS • i
MAKEUP AIR UNIT !
OVEN Ji
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER _
WATER HEATER �—
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG . Y 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 ❑
SIGNATURE OF OWNER OR AGENT j
y I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat the best of my knowledge
�� and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Lai
PLUMBER- SFITTER 1E LICENSE#J5 SIGNA RE
MP I MGF JP JGF LP ❑ CORPORATION❑ F PARTNERSHIIP❑## LLC❑COMPANY NAM JO6rY (i {' ADDRESS 6 t f—,(17 lint)
CITY / / T 1'— 0 �'` ( STATE.4fZIP 11� 7� TEL �`l �. O �7��
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No N/ A—
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ (((
FEE: $ PERMIT#
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