HomeMy WebLinkAboutBLDG-18-001678 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T0PERFORM GAS FITTING WORK
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CITY MA DATE
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JOBSITE ADDRESS /\��� H��E�S
`--~ o NAME|(~«/m'c/ K4�� <`/ ���
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0YNVERADDREGG | _W��� - f~ XTEU�D���g+ ��k�� XF8((
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OCCUPANCY TYPE COM MERC�L�r�~-
EDUCATIONAL �� RESIDENTIAL
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CLEARLY NBN:[j RENOVATION: REPLACEMENT:[2"- PLANS SUBMITTED: YES N0E--'
APPLIANCES-1 FLOORS-^ oaw 1 2 o 4 5 6 r V V 10 11 12 13 14
BOILER | �
BOOSTER
CONVERSION BURNER
COOK STOVE L 1 -41 L J{
DIRECT VENT HEATER |_ _
DRYER �
FIREPLACE _ ---_]____
FRYOLATOR
FURNACE | /
GENERATOR
GRILLE � 1
INFRARED HEATER -71
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNITTEST
__- - ` ..
UNIT HEATER
UNVBNTED ROOM HEATER
WATER HEATER _-- i -' _ ................... �
. OTHER
] � A
INSURANCE COVERAGE
|have a current|iabi|bv insurance policy wr its substantial equivalent which meets the requirements of MQL Ch.142 YES LINO D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY F�l OTHER TYPE INDEMNITY F-j 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 0F OWNER ORAGENT
/hereby certify that all m the details and information/have submitted o,entered regarding this application are true and knowledge
and that all plumbing work and installations performed under the permit issued for this application will uoinvomp|ian°'with ent provision of the
Massachusetts State Plumbing Code and Chapter 14om the General Laws.
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9LUM8ER'GASF|TTERNAME R-PETERCHECKUVW�' LICENSE#|13417 � ATURE
MP[j MGFEl JP JGFL] UPG|[j CORPORATION Ej# 4008 |PARTNERSHIP �- LLC|j# �
COMPANY NAME, `8OUR�UE G&HEATNCOOLING CO AADDRESS 1189P|TCHER3VVAY
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CITY MYANN|S STATE MA ADP102001 KTEL 508-780-2887
FAX 608-77 -9608 ICELL 508-735-9003 EMAIL info@bourqueheafingandcooling.com _� 8
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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