HomeMy WebLinkAboutBLDG-17-000442 MASSACHUSETTS UNIFORM APPLICATION FOR A. PERMIT TO PERFORM GAS FITTING WORK
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-U, cIT r 4?,,,M1 MA DATE �Zry - l�' PERMIT#,�t'�h%/-00404/Y/Z
JOBbITE ADDRESS /'5/,,9 ,4 W'n' OWNER'S NAMEd/-'/ /?Aibia..ee
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[�}�
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 0
APPLIANCES T FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER ---j
CONVERSION BURNER
COOK STOVE
DIRECT\/ENT HEATER
DRYER _ r
FIREPLACE — f
FRYOLATOR
FURNACE
GENERATOR _
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER _ --- —
ROOM I SPACE HEATER
ROOF TOP UNIT —
TEST —UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER —OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES nib ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I 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 / / "I f91,616'1( LICENSE# 1/6'/ SIGNAT
MP I MGF❑ JP❑ JGF ❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 77/,r,ii r/?`/6 c ADDRESS /( 6`n/'' fJ R EC E i E D
CITY / eirMG;/ STATE . ZIP d.7 '9_?
FAX CELL 724/-11E4`7(Y EMAIL JUL 2015
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BUILDING OEPARTf.`.ENT
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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