HomeMy WebLinkAboutBLDG-18-003693 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
;1 ,.y. CITY /aitVhi1-- , h4 DATE PERMIT
JOBSITE ADDRESS 4`) lc a (�1 2 J^ �lv
F. OWNER'S NAME o ��1 PrenA_K-
OWNER ADDRESS 3 i-Oi-ysr�2 Cs C, TEL ce e-3S-441 Z( FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 4
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:* PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —I
BOOSTER ,
CONVERSION BURNER
COOK STOVE - f
DIRECT VENT HEATER i
I
DRYER I I
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE 1
INFRARED HEATER I
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN 1.)i--! 1
POOL HEATER I • 1
ROOM I SPACE HEATER ��//� f�� i
ROOF TOP UNIT l�% - /
TEST ...
UNIT HEATER
UNVENTED ROOM HEATER _
WATER HEATER I
OTHER _
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES g NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY K 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
CHECK ONE ONLY: OWNER ❑ AGENT El1
SIGNATURE OF OWNER OR AGENT 1
s3. I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc to to the best of my knowledge
' - and that all plumbing work and installations performed under the permit issued for this application will be in compli e ' all Perti ovision of the
- Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#320 SIGNATURE
MP ❑ MGF❑ JP x JGF❑ LPGI ElCORPORATION❑# PARTNERSHIP[E# LLC❑# I
COMPANY NAME S t ,^„.._y p L'f'I�It '( ADDRESS 7'D Scvr-C 67z,t- it 6
CITY '/ ' , STATE AV ZIP O2-104 TEL
TEL 5�-i''ZZf _,5'25-1 1
FAX CELL r=i8-.Z21 S251 EMAIL 3-1— -j Co ( c c GtL L e-emi
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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