HomeMy WebLinkAboutBLDG-16-006940 1 '_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
Wa CITY Y MP, DATE 0 Zv A l PERMIT.r
JOBSITEADDRESS I2--7 UN/o SI'uL OWNERS NAME IN ; O Cu .)c,a.
GOWNER ADDRESS TEL Su `I68 vz zy FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL EEK
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4. BSM 1 2 3 4 5 6 7 8 9 10 'I'1 12 '13 14
BOILER I
BOOSTER j
CONVERSION BURNER
COOK STOVE I _
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
,
LABORATORY COCKS
MAKEUP AIR UNIT _ 1
'
OVEN JJ
POOL HEATER
ROOM/SPACE HEATER I
ROOF TOP UNIT 1
TEST
UNIT HEATER
UNVENTED ROOM HEATER --
WATER HEATER — i —I
OTHER I
I
INSURANCE COVERAGE 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES tr-NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0' 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 wives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 1.,11 t L)A-AA WI-4 ) 41 LICENSE# /Z d a/ SIGNATURE
MP ZrMGF❑ JP ❑ JGF❑ LPG' Li CORPORATION❑# PARTNERSHIP❑# LLC❑#
CGMI4ANLY- IAA -- -- ci Go-, 1'-' ADDRESS 2 4 S ?LeAl" w%e)r i 'Z."-h
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CITY . _-------��` STATE 4^/Y ZIP 02 6 d / TEL 77`/ / ' ?/7 U 1
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FAX ' 2016 ELL ro- - 71,- I0
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t EMAIL 3,//.4.4I 330 Co 5,.-7,4//. Cow
\ BUILDING DEPARTMENT _ /�//(� (''�`L
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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