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HomeMy WebLinkAboutBLDG-18-002733 MASSACFIUSETTS UNIFORM APPLICATION! FOR A PERMIT TO PERFORM GAS FITTING WORK ` WR CITY lct c+tAO MA DATE X X 1- ) t 1. PERMIT#/*der 0-71 JOBSITE ADDRESS Lj -A O.n 'r OWNER'S NAME (-d lre— GOWNER ADDRESS TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[� PST CLEARLY NEW:L RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES a. FLOORS-4 BSM 1 2 3 4 5 6 7 5 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY AIRY COCKS MAKEUP AIR UNIT 4 I OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST II - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER _ I 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 EV 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. 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT J 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 ce.with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter.142 of the General Laws. Lij PLUMBER-GASFITTER NAME LICENSE# t7 - SIGNATURE MP PIAGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑37: COMPANY NAME C-3j k.`4 ADDRESS l S CITY S\,,r STATE ZIP © &6`l TEL 50 - zw—`-1 elsiD FAX CELL EMAIL (f— J (io °UGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes too THIS APPLICATION SERVES A$THE PERMIT ❑ ❑ 7/7 FEE: $ PERMIT ft PLAN REVIEW NOTES 11,