HomeMy WebLinkAboutBLDG-16-006278 %OA3SACHUSETT8UNfFORM APPLICATION FOR APERMfT TO PERFORM GAS FITTING WORK �
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CITY W MA DATE *��~��-~4f PERNIT# -li -I-
JOBS|TEADDRESS OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERC|ALF� EDUCATIONAL F� RESIDENTIAL
PRINT ^� ^� ^�
CLEARLY
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YE8F-1 NOFl
APPLIANCES-1 FLOORS- B0N 1 2 3 4 5 5 7 8 8 10 11 12 13 14
BOILER
- �
BOOS-TER
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
|have m current liability insurance policy or its substantial equivalent which meets the requirements nYMGL Ch.142 YES ucrO [I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E~^ OTHER TYPE INDEMNITY E] BOND [I |
OWNER'S INSURANCE WAIVER: I ani 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 Fl AGENT ��
SIGNATURE OF OWNER ORAGENT
I hereby certifyall of the det tails 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 Linder the permit issued for this application will be in compliance with all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142of the General Laws.
PLUMBER-GASIF|TTERNAME '�7 L|C ENS E# -----' SIGNA
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MPE�MGFEI JP JGFEI LPG| E1 CORPORATiONPDT@�%-j PARTNERSH|PEJ# LLC[I# `
COMPANY NAME ADDRESS
CITY '~ STATE �^mK ZIP ����c�^��� TEL
FAX CELL EMAIL
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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
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