HomeMy WebLinkAboutBLDG-18-006588 .1::"...,.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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• JOBSITE ADDRESS -S HO U 55 )• OWNERS NAME JD� Aury
G OWNER ADDRESS TEL
C ( TEL ! 2/-7 t)—,661FAY
TYPE OR
OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL
PRINT
IUENTIAL�'�
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: E PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—F BSIA 1 2 3 4 5 6 7 f 9 10 11 12 13 1 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE �1
FRYOLATOR n�
FURNACE �I)
GENERATOR. I
GRILLE '
INFRARED HEATER
LABORATORY COCKS "E " ' r - ,F
MAKEUP AIR UNIT 1 ,SSS-
OVEN 1 1
04
1 , alb i,,
POOL HEATER J
ROOM I SPACE HEATERy nF p:. e , .'. ,.CO-
-'. it_i I
ROOF TOP UNIT ;H_UIN
J
TEST _, _..__._.d
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER ge5(__ (-f 5
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IIIID ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY 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 knowledge
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. l
PLUMBER-GASFITTER NAME LICENSE#3? -47 SIGNATURE
MP ❑ MGF ►[] JP❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# 1
COMPANY NAME #4P1)4Vla6C- // * — 41C ADDRESS 2 14-R' i / ,-
CITY ?7L f � STATE 4 ZIP C� o��C7 TEL �v p - R
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FAX CELL _S► `>e. -7� /Q---. EMAILkpV ( / CQm
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES