HomeMy WebLinkAboutBLDG-16-005990 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
WI!
CITY )lA2w,'sv rL MP, DATE 4'41 3 24/6 PERMIT#:c1l1c='r 11
JOBSITE ADDRESS 20 ''Y""` ' rt-Vt bA OWNER'S NAME J"--°S
GOWNER ADDRESS TELS°� 3 b Z SS‘L FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT
CLEARLY NEW: [] RENOVATION: ❑ REPLACEMENT: ❑ 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 I SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER !i!
UNVENTED ROOM HEATER
WATER HEATER j —I
OTHER
�II
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 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er 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
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.
nn G
PLUMBER-GASFITTER NAME W'""'"' I.1e' ' 'K LICENSE# M 1 202 I SIGNATURE
MP MGF❑ JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME c-3'!- S G en' ADDRESS 1�i 5/L l W z �reA'sj ✓L?"
CITY 14./1 t^'`e--1.- STATE 'M� ZIP 6-2-6 V f TEL ' 'Y VV 7 r/70
FAX CELL Sub 77L /OJS- EMAIL /t11s50n 330 Q. 601/9-iZ- . C,,..,
4/()(° 619'0
0
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
K6P- � � es No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES