HomeMy WebLinkAboutBLDG-20-003779 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
T _sH' CITY /C' ! V J I/t' . MN DATE PERMIT#&06- 17
JOBSITE ADDRESS.39 TI- c *s A- OWNERS NAME Se Ere Vie cili 1911.a.
GOWNER ADDRESS - • TEl : �j D FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ ESIDPRINT
EI�El
CLEARLY
NEW:❑ RENOVATION REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—I BSM 1 ? 3 4 5 s 7 II 9 10 11 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE /
GENERATOR I 1
GRILLE I
INFRARED HEATER —�
LABORATORY COCKS •
MAKEUP AIR UNIT
-OVEN
POOL HEATER -
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST - .
UNIT HEATER II
UNVENTED ROOM HEATER 1 •
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ❑ 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 valves-this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I:, 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 compile with all e in nt provision o' le
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP MGF[1] JP` ()❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
CO PANY NAME l� )>(,,74 �/e 11� ('�jj� ADDRESS i4 j Lia(-C6✓L S
CITY V U 0 1r& MA yl/J STATE/i 5 ZIP 0 2— 7/ TEL So-d) ,P-9!JAe/
FAX CELL_,5 - 74 - ODJ-EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
FINALiI�ISI'E(:1 ION�i�JG'I'ES
Yes No pi1hA.. LCe
/1 /,!� THIS APPLICATION SERVES AS THE PERMIT ID ❑ /�✓;. O l/
FEE: $ PERMIT f
PLAN REVIEW NOTES
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Gift 6,U
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