HomeMy WebLinkAboutBLDG-17-4109 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
` ,g CITY 5OOT►t ' /A TIA MA DATE 1+1 f I'l PERMIT# J 0-/I ad WI?
JOBSITE ADDRESS is tali LUJ t• OWNERS NAME SfthJ (web'
OWNER ADDRESS TEL /02, -14g-5sS FAX
TYPE OR.
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO Er-
APPLIANCES FLOORS-4 BSM 1 2 3 1 5 6 7 0 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER •
'
COOK STOVE
. I
DIRECT VENT HEATER
DRYER '
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATED. —�
LABORATORY COCKS •
MAKEUP AIR UNIT FEB
OVEN
POOL HEATER *64
ROOM I SPACE HEATER
ROOF TOP UNIT "
TEST - ..-..... -
UNIT HEATER
UNVENTED ROOM HEATER
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 '21/NO ❑
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 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
`— and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
1J Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#I Sy 4 3 SIGNATURE •
MP e- MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME C. PV-,"tbc 1-104(1'11 6 - ADDRESS 135— GiNG'Cbt-W Sn1Act- v -D
CITY S N(Jsmilc vTN STATE MA_ ZIP [J 244,4 TEL Ti L(-11 t(-! j'
FAX CELL EMAIL GAPE,.,.ti6Flk_atg t.- ` 4,4440 . cdlK
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLYIli{AI INSPECTION NO IEq
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT fI
PLAN REVIEW NOTES