HomeMy WebLinkAboutBLDG-18-006664 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
teRgAVAPCITY armo 1 MA DATE I PE,MIT#
JOBSIT ADDRESS ( g " F M ( '/ / OWNER'S NAME �Cri-za
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er-
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 119' PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-0 BSM 1 2 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
INFRARED HEATER
• i
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN lRl
1, ,r
POOL HEATER
ROOM!SPACE HEATER
1 ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 7
I‘t\ OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 2/NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ["'� OTHER TYPE INDEMNITY ❑ BOND ❑
J 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 l have submitted or entered regarding this application are tr 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 co lane with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME kit, b)14c5.101(1Y LICENSE#1/12/2 ` SIGNATURE
MP' MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY AME �l,., W#* P i' ADDRESS Cti�/(I15 kit/7
CITY 21 ��i'j - STATE 421A ZIP C `' `7Z TEL )?2JO 7t
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT D 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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