HomeMy WebLinkAboutBLDG-16-005496 - '_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t--�;iti--�" CITY �lji��'j'I�C1� MA DATE �-7- PERMIT# TXP b-/6' 0��g�
(�"� JOBSITE ADDRESS 2O 1.6 C4�`IZ a.iTh O� u. OWNER'S NAME gQ At I 4 A-
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OWNER ADDRESS �P fAC t 1 �d TEL C� FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL lit
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 i
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 I I
WATER HEATER
OTHER
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES j NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ZI 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.
PLUMBER-GASFITTER NAME /l///1/» G��/ LICENSE# �J_gge-!( S
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MP si MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION[ -# 3)-31 PARTNERSHIP❑# LLC❑#
COMPANY NAME Ill/, "7/rr /i`/' ADDRESS /1 eafii S/
CITY ,k STATE r174. ZIP Q Z TEL
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FAX CELL 77`/-434 -G 1Pi EMAIL f APR 07 2016
r LIKE)NG DLPARI 1111ENT
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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