HomeMy WebLinkAboutBLDG-18-03300 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
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��/s�l,( MA DATE //i�d/Z7 PERMIT ^��"/ I4f�J
JOBSITE ADDRESS OWNERS NAME
GOWNER ADDRESS Ce/ TEL FAX
TYPE C+ OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ::-.,
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: I PLANS SUBMITTED: YES❑ NA{I
APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE j
DIRECT VENT HEATER
DRYER '
FIREPLACE ' j
FRYOLATOR ,- ,ari! ,_
4 FURNACE ■■GENERATOR
GRILLE LIMIIUI j
INFRARED HEATER II Mann
LABORATORY COCKS
MAKEUP AIR UNIT 11/11
, ,
GONPOOOL HEATER
ROOM SPACE HEATER.*' ROOF TOP UNITTEST .UNIT HEATERjINVENTED ROOM HEATER I iWATER HEATER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.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 ❑
b 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 Eli
SIGNATURE OF OWNER OR AGENT f
7�; 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 provi+I 40 f the
Li) Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
1-PLUMBER-GASFITTER NAME LICENSE#�8,�� SI 4Thiri4— AT a
INI MGF❑ JP JGF❑ LPGI ❑ CORPORATION 4)S'7C PARTNERSHIP❑# LLC❑#
COMPANY NAME 4-91'L- de.49/4"4/6""l Ai,il6 ,ADDRESS 430/I? SS�8--1)2i VC
CITY YIM.4104 '2 STATE i i ZIP is a47/ TEL 67'8- -237-.4661 + 1
FAX CFt Cl ' _ //3 EMAIL TUmIn/C.� 4L/3C /1/n/L.t jGf
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE
Yes No /1/74— ,5Y/?�2—(
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: $ PERMIT#
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