HomeMy WebLinkAboutBLDG-18-000690 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY Gt/�/�1ri�t MA DATE ee'Z/� PERMIT#/.Y+�P ���U�G�D
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JOBSITE ADDRESS 3 9S /�, S�/�'�-; 6'9 OWNER'S NAME __.6.__ ecvetie +-�
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
—PRINT
CLEARLY Y NEW:❑ RENOVATION: e- REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-+ 6SM 1 ? 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 etna..e,€6 o i'iJf,/i46 - I
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT �{'.
r-
OVEN � • I
POOL HEATER 20,O� j
ROOM/SPACE HEATER AJG ;
ROOF TOP UNIT MAL
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 MGL.Ch.142 YESEl-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
Massachusetts General Laws,and 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
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 /7 LICENSE# 98'0 SIGNA
MP MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION-'32 3`J PARTNERSHIP❑# Lc❑#I.
COMPANY NAME Q//�a/)7.T //T ADDRESS /7 er/l,S�
CITY %; emah STATE l2Gi ZIP 02 6'7 3 TEL
FAX CELL 774 I 6-G�J ' EMAIL 6f6p zC "/e- 7@ a6/, 6
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
.FINAL INSPECTION (O TI S
No
PO/A- 01/e_ THIS APPLICATION SERVES AS THE PERMIT 'des
/107-4-- //2 FEE: $ PERMIT ft
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