HomeMy WebLinkAboutBLDG-17-005167 -;11N.` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
``- P; CITY /(,-1C/I/1 Ol, y MA DATE ! l0/l ' PERMIT tf 3* ()—i7 5/jO
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JOBSITE ADE4 d!�i( /. l OWNERS NAME
OWNER ADDRESS l/L , TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 1?1
PRINT
t h 3✓A_> T NEW:[Z( RENOVATION: ji REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO4
APPLIANCES FLOORS BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER r
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
_ I
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` GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I 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 J
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accu 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 wi Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 o. e Generalra Laws.
PLUMBE GASFITTER NAME CJ��yl O �ie`� LICENSE#�,67v SIGNATURE
MP I MGF❑ JP ❑ JGF❑�GI ❑ CORPORATION❑# PARTNERSHIP❑it LLC[ 31;f 5/ I
COMPANY NAME �/ `�' IVioes/"171"1U ADDRESS l o` /i/zo !% yA,z/oi
CITY !/Yew`' STAT4.4 ZIP Q '
FAX CELL EMAIL ApR 0 2017
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL,INSPECTION NG`I'E�
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ,/
FEE: $ PERMIT
PLAN REVIEW N�NOTES (3r-
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