HomeMy WebLinkAboutBLDG-17-001668 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY )4244)citi: \ MA DATE PERMIT# /Y-�f1�»'4O/l/f
JOBSITE ADDRESS al NIC6ie hlU,c OWNERS NAME(s.)
OWNER ADDRESS TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,®'
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO ❑
APPLIANCES FLOORS-- BSIJ4 1 2 3 4 5 6 7 5 9 10 11 12 13 J 14
BOILER _
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN _ }}i
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST _
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
Ch/A14-ey/A)0.. /
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES,, NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE EY 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 accu to 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 wit II P rtinen rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME,4f A) 2Arl LICENSE its-O SIGN URE
MP ❑ MGF❑ JP❑ JGF /LPG_I t❑ CORPORATION❑# PARTNERSHIP❑/# LLC E#
COMPANY NAME e Slr�x s CLz4j' ADDRESS
CITY C kztf!6 -e STATE dl- ZIP ()mod T Ci2
FAX CELL EMAIL/444R,S !'VI%-G L C-v A
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