HomeMy WebLinkAboutBLDG-19-000846 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITYvV t /���r PERMITtt�N/FIce4!(F�
e j ,s MA DATE
JOBSITE ADDRESS (I- 2.4, OWNER'S NAME-Le/AO" de—/h1�e,
OWNER ADDRESS TEL FA.Y
TYPE OR
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
YET CLEARLY
/
NEW:❑ RENOVATION: ❑ REPLACEMENT: [vC" PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-4 BSM 1 2 3 1 5 6 7 ° 9 10 11 12 *13 11
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
- - i
DIRECT VENT HEATER
_ l
DRYER
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR
GRILLE I
INFRARED HEATER t� I
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN ,_�
POOL HEATER P)
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST .
UNIT HEATER _
LINVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or it substantial equivalent which meets the requirements of MGL.Ch.142 YES - d'-0 ❑
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.
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 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 with all Pertinent provision of the
- Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ,d(if G(/OC aJ LICENSE# /I1 7 SIGNATURE
MP I JGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION I PARTNERSHIP❑# LLC❑#
COMPANY NAME / � S i/Cf'4/Z ADDRESSA12) .4a
CITY 4), 4#4/ STATE //F ZIP 6 a i 6 TEL p 0 A 8 3 7
FA.X 3 lo� %2 <3 CELL, 5 3 62 3ff,5 EMAIL 4a�s /D( /'/ CzAiJ) I _
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY __FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑•
❑
PEE: $ PERMIT#
PLAN REVIEW NOTES