HomeMy WebLinkAboutBLDG-18-003230 MASSACHUSETTS UNIFORM APPLICATION FOR A PER IT TO PERFORM GAS FITTING WORK
P` l" CITY 3. MA DATE // 27 /7 PERMIT#' /0-OO 0-10
JOBSITE ADDRESS /L5 7fer•C C/ OWNERS NAME
GOWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL a'
YET
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS—I BSM 1 2 3 4 5 6 7 8 9 16 11 12 '13 I 14
BOILER /
BOOSTER
CONVERSION BURNER __,
COOK STOVE _
DIRECT VENT HEATER
DRYER
FIREPLACE
,
FRYOLATOR j
FURNACE
GENERATOR I
GRILLE —
' INFRARED HEATER
LABORATORY COCKS —~ 1 • I
MAKEUP AIR UNIT .
OVEN I , 1
POOL HEATER 1 ; 1
ROOM I SPACE HEATER _ �� )
ROOF TOP UNIT
TES !�
T � �� �,s'���e _
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
OTHER I
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E 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 []
SIGNATURE OF OWNER OR AGENT
r., I hereby certify that all of the details and information I have submitted or entered regarding this application are tr a and accurat 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 I' ce w a ertinent provision of the
�� Massachusetts State Plumbing Code-ndchapter 142 of e General Laws. j
PLUMBS GASFITTER NAME ti a LICENSE#/ 0Z SIGNATURE
MP MGF❑ JP ❑ JGF LPGI CORPORATION # PARTNERSHIP # LLC
COMPANY NAME 144,11 UariC /'/JY ADDRESS � / e t///nt 4 V'T
CITY04vileCW/ STATEMA ZIP 024.37 TEL ca.' Z'`t P" ,1763 I
FAX CELL EMAIL
` CC
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
(es No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES