HomeMy WebLinkAboutBLDG-18-002094 S"'" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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` s" CIT( M�/, DATE/ /0 d PERMIT.� / I /� /
- JOBSITE ADDRESS -3'� N�2 L Il - OWNERS NAME C�"t'--1/�Ik4 0
GGWNER.ADDRESS I t ( TEL / 36 - - o2 J FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLYNEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ '
APPLIANCES-1 FLOORS-- BEM 1 2 3 4 5 6 7 _ 5 9 10 '11 12 '13 I 14
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER I
DRYER
_
FIREPLACE
FRYOLATOR
FURNACE Y
GENERATOR
GRILLE _
' INFRARED HEATER 1 __I
LABORATORY COCKS
MAKEUP AIR UNIT ,
OVEN
POOL HEATER "1'i
ROOM I SPACE HEATER 'i .- ...--a
ROOF TOP UNIT to
TEST .. �,1�._
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.1142 YES dNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE' .E EY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY ❑ BOND ❑ 1
• 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 LY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
•-i:• I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd accurate tote st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com ance with all- erti provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (/ eli
PLUMBER-GASFITTER NAME LICENSE# •315 1 SI ` ATURE
MP ❑ MGF❑ JP ❑ JGF ILPGI ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑#i:
COMPANY NAME /Tl r4 17 i -41( ADDRESS 1 A-1 f4u (?O.
CITY 1 1-\I b 40(.JT -I STATE Wiii, ZIP 0a?6.6.) TEL C -'75--C?
FAX CELL (- r t' (2 [-9t I a EMAIL Ap tAm- 1E.E RE4I`AC ,i ( . coil,
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY __FINAL INSPECTION NOIEc'
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ []
FEE: $ PERMIT t(
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