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HomeMy WebLinkAboutBLDG-18-002514 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •` ` j) l C31 Z. 7l 0 PERMIT /�` t .6 CITY Sots 1�j VA t t�l n. j Li MA DATE 1 / t /r'& 2O7y JOBSITE ADDRESS / t(' )L 1F:te fS d OWNER'S NAMe,az_ .I'r"T��.1 OWNER ADDRESS '^'« TEL 1 t �`rV 4 KY/ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL©� PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: I]V- PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-4 BSN 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14 BOILER ' BOOSTER --j CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS j MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER CI 1 ROOF TOP UNIT TEST . . - l UNIT HEATER G - UNVENTED ROOM HEATER WATER HEATER l OTHER _ I INSURANCE COVERAGE i have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES R1<1O ❑ 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 ❑ SIGNATURE OF OWNER OR AGENT I hereby pertify 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 theta work and installations performed under the permit issued for this application will be in cornwith a ro ' n of the - Massachusetts State Plumbing Code and Chapter 142 of the General Laws.LEJ PLUMBER-GASFITTER NAME LICENSE# I 'y4� 'IGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PA.RTNERSHI # LLC❑# COMPANY NAME ADDRESS Pa defy Li/3 CITY I/111 S T �I /1^)11-4 S190e- STATE fr-"f ZIP d ZL ) TEL FAX CELL ( 739 - G /L/ EMAIL L-c_JS it14/ L 400"7 ROUGH GAS INSPECTION TIOI NOTES THIS PAGE FOR INSPECTOR USE ONLY _FINAL INSPECTION t IQTE Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 4 - �/w l Zoi �-