HomeMy WebLinkAboutBLDG-17-000680 • /� B
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY %1 'rl'`%--()J 4 MA DATE sit( i PERMIT# b-,17.- olt
JOBSITE ADDRESS l t. a,e'^.,e-f'-.-( lelc ^�-7 OWNER'S NAME � -�-��,4 '
GOWNER ADDRESS SA / TEL c..4 r'i8^31-t'-(ii.
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL n--------
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-F BSlvl 1 2 3 4 5 6 7 8 9 10 11 12 '13 f 14
BOILER I
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER, I _ _
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR 1
GRILLE _
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM;SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER ' •
1
INSURANCE COVERAGE '
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [- 'f:i.
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE B ECKING 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 waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I he -•y 14 i at 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 bing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
M- sState Plumbing Code and Chapter 142 of the General Laws.
PI • , •-GASFITTER NAME c,2 6Zor- LICENSE# 1 c'ZZ SIGNATURE
MP I-- MGF❑ JP GF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 41 -I -,✓•-•.-0o r•- 1 ,v...-A:-t) ADDRESS -1 - A 1-E.,,---1-c1.-,? lam'p- fr‘.3-`—
CITY L-e/V f r-- ,-. l^-• STATE ZIP C. 1.-C-e.� 1 _ TEL Sb1- 3 d )^'ZCe V t._
FAX. CELL - 9,1---1 < •4 EMAIL_-_-._ '_x-_% v• f t__ k.,,._
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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#I
PLAN REVIEW NOTES
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