HomeMy WebLinkAboutBLDG-18-005857 MA sSA.CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`:���6 CITY �/e � MA� � � DATE � /C7 PERMIT* *fib-fir-ow 7
JOBSTE ADDRESS � .5.---1,'/�//7 Jr/ OWNERS NAME ‘-,evieere
OWNER ADDRESS G✓�' �� TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALPRINT
CLEARLY NEW:[r RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES:I FLOORS--I BEM 1 2 3 1 5 6 7 ° 9 10 11 12 'I3 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/SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
INVENTED ROOM HEATER / LI D J AV"
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
OWNERS 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 ❑ 1
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.
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PLUMBER-GASFITTER NAME LICENSE#" Welt SIGNATURV
MP MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION Rai 3239 PARTNERSHIP❑# LLC❑#t:
COMPANY NAME d// /�iIr�142',7 ADDRESS /1 ' 7// 5
CITY GIB `�L> /7/O</J`4 STATE GM. ZIP eV673 TEL
FAX CELL �1/-Pb/671ei EMAIL (s11,Z6 i? -s-/ 46(. "-�
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY _FINAL INSPECTION c
Yes 1d
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ --
-/•- (7- 1 (/' fr FEE: $ PERMIT f
PLAN REVIEW NOTES