HomeMy WebLinkAboutBLDG-17-002447 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j
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JOBSITE ADDRESS / V/i/i > _ e/4--(.2 Cli WNER'S NAME 17"-J9 -S0G`-"-
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[------
PltNT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: B� PLANS SUBMITTED: YES] NO❑
APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 9 10 11 12 'I3 1 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER ✓ `� ' l I
_
9 c3P
FIREPLACE U"
FRYC)LATOR
FURNACE
GENERATOR.
GRILLE ,�___, I
INFRARED HEATER. I
LABORATORY COCKS •
MAKEUP AIR UNIT I
OVEN ,�/J C' - j'D -
POOL HEATER • `�d� y 1
ROOM I SPACE HEATER i
ROOF TOP UNIT
______ ,K=1,, ,.
TEST_.
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NICL.Ch.i42 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 ❑
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.
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I
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 compliance wi all Pe ' ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# /7/65( SI ` ATURE
MP t4' MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATIONC ❑# PARTNERSHIP❑# LLC❑#
NAME C,7-� /!/ ADDRESS .S�V A-�4 &
CITY <</'--"---t-K1 STATE�‘/---- ZIP 0 2- 2 TEL L 2�)7 e
FAX CELL EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
N16 is r yr ,rur 011 Yes No r)O 7/ - c
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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f'6 o s C// ( FEE: $ PERMIT#C /74-4-,✓/T f4/ 15
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FLAN REVIEW NOTES
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