HomeMy WebLinkAboutBLDG-18-002313 :;'7".•.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
k: 6 CITY 44{? !JT ls( MA DATE /D 'l 7 -/7
PERMIT#/ - -/d'd �r7 ��J
JOBSITE ADDRESS 6-5- /?. 1jJKAW,v4wXur OWNER'S NAME (. 1' £/v4!
OWNER ADDRESS TEL Spa 3r N 6 a FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:Mr PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--F BSM 1 2 3 4 5 6 7 8 9 10 11 12 613 14
BOILER _
BOOSTER _____
CONVERSION BURNEP,
COOK STOVE _
DIRECT VENT HEATER
DRYER '
FIREPLACE I
I
FRYOLATOR
FURNACE s/
GENERATOR 7 ,- &0 r 60
GRILLE I
INFRARED HEATER _ _ I
LABORATORY COCKS I
MAKEUP AIR UNIT OC T .{ I
OVEN
POOL HEATER 0 44( 6411
ROOM I SPACE HEATER
ROOF TOP UNIT 1
TEST I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER Re,01LF l SST- I
1----- \ I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equi ent which meets the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE 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 ❑ j
--, SIGNATURE OF OWNER OR AGENT ,
yt, I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to the t of my knowledge I
\� and that all plumbing work and installations performed under the permit issued for this application will be in compl. e with all P 1h ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
PLUMBER-GASFITTER NAME LICENSE 1/ 34in SI ATUR
MP ❑ MGF❑ JP ❑ JGF LPG! E CORPORATION❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME ikki.)19414e- f t 4("-4/c - ADDRESS v. I�i41 lU l� .
JJ''
CITY V� i�.IU.1�[�( STATE C.�3) TEL - 7
FAX CELL WI - 1 >-Y (vZ AIL A !4' r�t G 1)101 cO ePt
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
kil�rAi INSPECTION NOTEg
/(C/� Ye; No
(91/ �� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
? l>") FEE: $ PERMIT#
/ l PLAN REVIEW NOTES