HomeMy WebLinkAboutBLDG-16-006985 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r__sri
E CITY . LI l i ,J iNi1_GI i0 errk _ MA DATE 4.4 G► I t R' :PERMIT# b 16 /o 1q;
JOBSITE ADDRESa ' nit(-91 J tt4 /_ _j,-e.owtie 's NAME
GOWNER ADORES,- - - TEl (4 2- ;FAX;
��OR OCCUPANCY TYPE COMMERCIAL EDU
CATIONAL 1-1 RESIDENTIAL
RESIDENTIAL
CLEARLY NEW: j RENOVATION:,' REPLACEMENT:[J PLANS SUBMITTED: YESij NO
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1,
BOILER
BOOSTER . . . ._ _ :_
al
CONVERSION BURNER _..._ MI IIM _ ) _ MI
COOK STOVE _ - gni M. �
DIRECT VENT HEATER umumOM MI SIP ME UMW M
DRYER —11
FIREPLACE M Wan IIIII . _ W s
J FRYOLATOR Jill.AM INN MIMI - - �.
i FURNACE I MN -- _ __
GENERATOR —_-_. _. ._
_. =FM__ . air_ _ _
GRILLE . _ _ _M _-
INFRARED HEATER
LABORATORY COCKS - _ _
IIII
MAKEUP AIR UNIT I1.1 MUM _ t'
f OVEN — --
POOL HEATER aim* .
ROOM I SPACE HEATER _ L ___ 21111W=UM
ROOF TOP UNIT
- _
TEST NI MO _ NI _ _
UNIT HEATER
UNVENTED ROOM HEATER _
WATER HEATER maw.. _ RR _yy. ___
OTHER
111111KM IMIIMIMMIE Willr 1 -'
7- ---- - --- --- - - - — . II MIR _MS . _
INSURANCE COVERAGE —
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YESAI NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING ME APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY4 OTHER TYPE INDEMNITY YI BOND LI
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Genera Laws it eand that my signature on this perm appication waives this requirement
1 — CHECK ONE ONLY: OWNER . AGENT n
SIGNATURE OF OWNER OR AGENT
I hereby certify that an of the details and itdonnation I have subrited or erie ed regarding this application are true and accurate to the best of my knowledge
and that an plumbing wait and installations performed raider the permit issued kw this appicaion wall be in compliance ,rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
{)is 2 L- .tit
PLUMBER-GASFITTER NAME( iv1.I)PI L,F)Ettt:O&jJ I UCENSE# SIGNATURE
MPX MGF!LI JP D JGF J LPG L CORPORATK)0I1# }77 !PARTNERSHIP I#i 1 LLC n#
COMPANY NAME: GCar `,in ilge-t-1 *J JADDRESS! 2.3 L-ince�i7 ,4 c
j CITY • Ph r/1 1iL/Je _ 1 STATE ,1 ZIP ed 76 TEL - gt-55i6---y .
FAX ltfgl-sccOj CELLS IEMAILjLOFic o Ph2ingrd&&'(T ( k'�_[
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
II