HomeMy WebLinkAboutBLDG-18-000446 ,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
i 1W if!,
'Oe
WCITY Y rrYioeml-�/l Gj MA DATE 7//-6--#6)(7 PERMIT* I -�U/ 6n
JOBSITE ADDRESS /713 'rat Z(k574-eri.) Kr/ OWNERS NAME , 1,/( i_.1 N 1 (3Cl14Z
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ler
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES T FLOORS-* Km 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
______IBOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER —_
DRYER
i
FIREPLACE '
FRYOLATOR 1
FURNACE / 1
GENERATOR
GRILLE '
• INFRARED HEATER 1
LABORATORY COCKS
MAKEUP AIR UNIT 1
OVEN i
POOL HEATER
ROOM/SPACE HEATER. i
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 IUIGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY 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
't Massachusetts General Laws,arid that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑ I
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 accurate to the best of my knowledge I
and that all plumbing work and installations performed under the permit issued for this application will be in compliapce wit II P i nt pray' ion of the
vMassachusetts State Plumbing Code and Chapter.142 of the General Laws. � 4 l
PLUMBER-GASFITTER NAME .>`lr-- „r /7455e 1/1 LICENSE# //6Y_ SIGNATURE
MP !V--MGF EI JP ❑ JGF❑ LPGI ❑ CORPORATION❑#3igt, PARTNERSHIP❑#�, LLC❑#I
COMPANY NAME 55(W 7�•'n1/K5' , 1",e ' ADDRESS 7,. /- 'd— /`11"" -
CITY Xtii-^rner/lil gt-7‘-' STATE /yf 4 ZIP 7,5- TEL 4-7 2 4"/7,S`.Y
FAX CELL 5 7-o�37 02/2S- EMAIL 1 #P' .f 42-55e ff€4.2S'rviV.• e,
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