HomeMy WebLinkAboutBLDG-16-004169 1 `, MASSACHUSETTS UNIFORM APPLICATION FOR A PER 0 PERFORM GAS FITTING WORK
�=gi CITY yzy,"4,(20,4,1` MA DA E ///�lb PERMIT# FiAr) /F-e-t2WDl
JOBSITE ADDRESS � W A/0� 4'l 7 (1)(// OWNER'S NAME �� �i G�� ����1 M NT ,
GOWNER ADDRESS /1- TEL 666 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL Z
PRINT
CLEARLY I NE6
W RENOVATION:-] REPLACEMENT: Z] PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER _ _
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _
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
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 El 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 accura to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp'ak�ce with Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of�he General Laws. //�' /
PLUMBER-GASFITTER NAME iv/4'�ly" Vaia LICENSE#6 G% -SIGNATURE
MP MGFl// /
L'J ❑ 6-/-1/1/
JP❑ JGF❑lPGI ❑ CORP RATION ❑# PARTNERSHIP❑# LLC # 51/
COMPANY NAME yU/L'/) 71 L ADDRESS/d /6'0'�'G O P O 'CG''�/0�"
CITY Gay' �� STATE Alid ZIP O/`'6-7 TEL 5U2 p,7,2,
FAX CELL EMAIL
ijel 0'Xi
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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 ❑ ❑
,/�' �� 0 l/ L/7/6
FEE: $ PERMIT#
PLAN REVIEW NOTES
7
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