HomeMy WebLinkAboutBLDFG-19-000464 I>liASSACHUSETTS UNIFORM APPLICATION FOR A ERMET O PERFORM GAS FITTING WORK
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p� n J CITY �1 I` � _�T� MA DATE 2Ci. PERMIT#0/ L�'"/9/d��V
�� JOBSITE ADDRESS f 0 /L 'l L-_ ,1 OWNER'S NAME fP�(�_ /
GOWNER ADDRESS C TEL FAX
TYPE OR OCCUPANCY T YPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ri.----------
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—I. BEM 1 2 3 4 5 6 7 8 9 10 11 12 *13 14
BOILER
BOOSTER
I
CONVERSION BURNER _____1 _
COOK STOVE i
DIRECT VENT HEATER
- I
DRYER •
FIREPLACE '
FRYOLATOR
FURNACE _ - T
GENERATOR yy
GRILLE I
INFRARED HEATER MO
LABORATORY COCKS �v``��
MAKEUP AIR UNIT 70 r) � !
OVEN .11Z,_S El
POOL HEATER y
ROOM/SPACE HEATER - l
ROOF TOP UNIT
TEST
UNIT HEATER
(INVENTED ROOM HEATER
WATER HEATER 1
OTHER
_
INSURANCE COVERAGE /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES [ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
i
• 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.
1
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 acc ate 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 wit Pertinent provision of the
4- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i
.....N._—
PLUMBER-GAS ITTEP E LICENSE# ``6-Z�i� " SIGNATURE
MP I viGF E� y� — JGF LPG( 0 CORPORATION 0# PARTNERSHIP t
COMPANY NAME l i � C� ADDRESS 2 \ U
CITY y �"�Gtmoo c,) STATE' 1 ZIP CZ' 75 TE?O 360 ,( 5
FAX CELL EMAIL D 1-) L
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT•
❑ ❑
FEE: $ PERMIT tt
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