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HomeMy WebLinkAboutBLDG-19-001370 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK : ,_. Wars �' /5,k1 Dbl37° CITY .So v h MA DATE PERMIT�+ JOE5ITE ADDRESS G 3 OC�n OWNER'S NAME GOWNER.ADDRESS (OS ©CS P_A".. AVQ TEL saa'77c,' 3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL K( PST CLEARLY EA Y NEW:NI RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ I I APPLIANCES 1 FLOORS- BSlVI 1 2 3 4 5 6 7 8 9 10 'VI 12 '13 14 I BOILER I BOOSTER I— CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER --I DRYER —� FIREPLACE FRYOLATOR FURNACE GENERATOR 1 , GRILLE -_-- ' INFRARED HEATER _ _ i LABORATORY COCKS r I MAKEUP AIR UNIT J OVEN POOL HEATER 1�` ROOM I SPACE HEATER 41' ;71-11,4—;- I ROOF TOP UNIT _ TEST UNIT HEATER UNVENTED ROOM HEATER 1 WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL.Ch.142 YES ® NO ❑ 1 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. I 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 true and accurate to th est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance ' all P . - provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r I PLUMBER-GASFITTER NAME LICENSE##3 SIGNATUR-"- MP ❑ MGF❑ JP X JGF❑ LPGI`❑ CORPORATION❑#i &PARTNcERS_HIP 0## LLC❑#f COMPANY NAME � r f 1 in cr) ADDRESS 16 WSIc — -t. Q CITY SoW.‘ YttiriNdlat-tSTATE MA ZIP 02.661 TEL ,S321'GiliF *k FAX • CELL S6=22t-s? 1 EMAIL JtdcwA / I-@ Gala I L>C.c+AI it 450 - ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL IIEISPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT f PLAN REVIEW NOTES