HomeMy WebLinkAboutBLDG-19-002285 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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W� ,r CIT( J[+k-Ch '`itr, � % MA DATE lli ri f� - PERMIT* "i oCg p
JOBSITE ADDRESS 19 WWriu:ic - AVE. OWNERS NAME S �j' j �ck( Qt
GOWNER ADDRESS 1� lo "`eA VQ TEL 258-)37" 939S—FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL A
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CLEARLY NEW:XI RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--I BSM 1 2 3 1 5 6 7 8 9 10 111 12 13 I 14
BOILER ■
BOOSTER
CONVERSION BURNER, ■
COOK STOVE 1111
DIRECT VENT HEATER L_
DRYER
FIREPLACE
FRYOLATOR _
FURNACE
GENERATOR
GRILLE ■ ■ II
■ _
INFRARED HEATER
COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER {
ROOM/SPACE HEATER -
ROOF TOP UNIT _
a
TEST -. . .
UNIT HEATER i
UNVENTED ROOM HEATER Cl i! '/
WATER HEATER /+'
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [I NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Tiz OTHER TYPE INDEMNITY ❑ BOND ❑
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does riot 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 j
I hereby certify 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
`s- and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi II Perlin provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE#3 p SIGNATU
MP ❑ MGF E JP ti JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC E
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COMPANY NAMEST 151&.Q%.Qy t)L z� b `ADDRESS / ett k k'8
CITY `tost(Y1 STATE MA- ZIP 6tWQ J TEL sae-Z/Zi-2r$-7
FAX CELL $ i-22,1 -S-Zs 7 EMAIL_�i-Jc„v, j (o t_ F-°CO)r1
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ROUGH GAS INSPECTION PNO'T'ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes N
0/1‘C ze/ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: v PERMIT t
PLAN REVIEW NOTES