HomeMy WebLinkAboutBLDG-18-04341 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.t< -_„6N CITY dom.? Q MP DA E 02 / I PERMIT* e l /27=0i`f8// ;
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JOBSITE ADDRESS S1 C.1:e '/ P" OWNERS NAME &A"m"
GOWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
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APPLIANCES 1 FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 'I'1 12 13 14
BOILER ___
BOOSTER --j
CONVERSION BURNER, -
COOK STOVE /
-1 1 'Mill DIRECT VENT HEATER
DRYER
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR
GRILLE tillel ■ ■
INFRARED HEATER. �R
LABORATORY COCKS
MAKEUP AIR UNIT ..: "' ' 1
OVEN r � \ ' \
POOL HEATER '.-2 / ..\ _ .1
ROOM/SPACE HE " _i I ? .
ROOF TOP UNIT ,'' /-
TEST F~���
UNIT HEATER
UNVENTED ROOM HEATER`
WATER HEATER r
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of FNGL.Ch.142 YES eNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE yE 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. I
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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 tru=an. accurate to the best of my knowledge
`k- and that all plumbing work and installations performed under the permit issued for this application will be in comp -► a /41
Pertinent provision of the
B Massachusetts State Plumbing Cod nd Ch ter 142 o the General Laws.
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PLUMBS -GASFITTER NAME �� LICENSE#r0/2 ' i SIGNATURE
MP MGF❑ JP JGF LPGI CORPORATION #❑ ❑ ❑ ❑#E PARTNERSHIP❑4,4'
LLC❑#
COMPANY NAMEIii () 1 / 44 ADDRESS 77 W/
CITY04/774?-afSTATE 444( ZIP 652 TEL y), 7S £16J
FAX CELL EMAIL!imeloa 37 kitih f i , 00-71
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY _FINAL INSPECTION iO�{ OTEq
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
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