HomeMy WebLinkAboutBLDG-17-006565 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
:k CITY______cat //r�//1 MA DATE 0 6 / / ( / PERMIT* 0066-4
JOBSITE ADDRESS 47 d-c ie c " 'e .� OWNERS NAME
OWNER ADDRESS $Sc( L TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
)P] T
CLEARLY NEW:❑ RENO\/ATION: ❑ REPLACEIJIENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS--I BSM 1 2 3 4 5 F 7 ° 9 10 11 12 13 j 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE l/
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST . . _
I Li Ark ___
UNIT HEATER IOW
UNVENTED ROOM HEATER i:SVW
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of 1 GL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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 waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 Imowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Q.)
PLUMBER-GASFITTEF,NAME LICENSE# SIGNATURE
MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑
COMPANY NAME A'?4 C-C'�/ .�////ljGJ y a74 ADDRESS 47/7 /� �/ t t"✓'/ 2�jl?
CITY Wa> t ,e e G STATEftieL ZIP c-Z 6 19 TELXFF FAX $ '1F CELL, /` -2 - ?X EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
I'Ih{AL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT f
PLAN REVIEW NOTES