HomeMy WebLinkAboutBLDG-18-003598 ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
I.�r�ri'I��j� W �f/ y�
`=` CITY " lvi v MA DATE PERMIT* 6 'PV
JOBSITE ADDRESS 31 r2A1 BSI /- D OWNERS NAME
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL rJ
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:, PLANS SUBMITTED: YES] NO❑
APPLIANCES 1 FLOORS-- BSIJM 1 2 3 4 5 6 7 8 9 10 11 12 '13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER _
DRYER I
. -
FIREPLACE '
FRYOLATOR
FURNACE I
GENERATOR I
GRILLE
INFRARED HEATER. )
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN i
POOL HEATER
ROOM/SPACE HEATER - I
ROOF TOP UNIT —
TEST �
UNIT HEATER
UNVENTED ROOM HEATER ezi --r--"
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or it substantial equivalent which meets the requirements of NIGL.Ch.142 YE&IO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .B' 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
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 corn 'a e 't all P ' ent provision of the I
1 Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# 1261 Ti SIGNATURE
MP �v1GF Zr JP'GF❑ LPG! ❑ CORPORATION # `10 c PARTNERSHIP(]# LLC❑# 1
COMPANY NAME �i Un 0(47-7-571/C1161 ADDRESS / Al. L4/flN SF
CITY FA ,)V 71f STATE ZIP D 2,CY � 2 E�a6 p' TEL 5 -3
FAX CELL EMAIL M/ 4(O//`D�-&l tf- ---fII (l d74E-VLSI y
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
@p, L `P W- THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
/lC /6 /7 FEE: $ PERMIT#
PLAN REVIEW NOTES