HomeMy WebLinkAboutBLDG-19-000202 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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MA DATE �//C'I / j' PERMIT# ,e -/9 O(20:2
JOBSITE ADDRESS 9 5',,??,�, / '��"C�/L'2kilt
-/ ,z o OWNERS NAME Q ch,✓ //G t�.3,,
GOWNER ADDRESS 4g//c'= L't S I ' k4 7t -i TEA 3if-61,4-S FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS— BSIv1 1 2 3 1 5 6 7 8 9 10 11 , 12 13 14
BOILER —1
BOOSTER
CONVERSION BURNER,
COOK STOVE -i'
DIRECT VENT HEATER
DRYER , /I _ '
FIREPLACE /�
FRY OLATOR —~
FURNACE / /
GENERATOR 1
GRILLE I
INFRARED HEATER I
LABORATORY COCKS - I
MAKEUP AIR UNIT
OVEN
POOL HEATER • _
ROOM I SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER 1
WATER HEATER _ l
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 1
Irmo 1
LIABILITY INSURANCE POLICY 0� OTHER TYPE INDEMNITY ❑ BOND ❑
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by C_hgp ,142,�of he ' 4
Massachusetts General Laws,and that my signature on this permit application waives this requirement. 6/4 7
I
i.
, CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1
SIGNATURE OF OWNER OR AGENT
`-• I hereby certify that all of the details and information I have submitted or entered regarding this application argil e 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 liance with eertineimt Provision of the
i
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# //./rjp/eip,y SIGNATURE
MP I MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP❑# LLC❑# I
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COMPANY hlAAM G F1� C I 1( C ADDRESS r/- LE�3' 1 - GL' --ef, + /144
CITY VGI A -rt�"�IY1 STATE VII-J4 ZIP C)011 y5 3 TEO 903 -6-t/9S- 1
FAX CELL EMAIL 1 GI'1 -t EPA)al a -en1 C-Ce`ii IP
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY __FINAL INSPECTION NOTE`
Yes No
pa-2/7/ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
/vp~ / FEE: $ PERMiT
PLAN REVIEW NOTES