HomeMy WebLinkAboutBLDG-19-003394 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORMGAS FITTING WORK
`` 6t, CIT( yy,/ t v /1t MA, DATE /1 3o /r PERMIT# i /?'C YVf
JOBSITE ADDRESS /. f/AL(!ti)e- Ft-if OWNERS NAME '
OWNER ADDRESS 5s. TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Kg-----
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOORS-- BSM 1 2 3 4 5 6 7 ° 9 10 '1'1 12 13 I 11
BOILER t/
BOOSTER
CONVERSION BURNER,
COOK STOVE _
DIRECT VENT HEATER
1
DRYER
FIREPLACE _______1 ______I
FRYOLATOR
FURNACE _
GENERATOR.
GRILLE
1
INFRARED HEATER I
, , I
LABORATORY COCKS •
i
MAKEUP AIR UNIT I
OVEN i
POOL HEATER •• 1
ROOM!SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER _
UNVENTED ROOM HEATER
WATER HEATER
OTHER _
- I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑
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.
I
CHECK ONE ONLY: OWNER ❑ AGENT El
SIGNATURE OF OWNER OR AGENT j
si, 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 I
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME per. ( l l� LICENSE#116� �1.1.1 SIGNATURE
MP l MGF ElJP ❑ JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP❑# LLC El#
COMPANY NAME Via it p+ k ADDRESS 7 a 54140J e "'Pam'( okr
CITY i `s 14 JL STATE ei - ZIP C Z b V
� !� I/ TEL S�f- 5-3`1 0 Zc1 __
FAX CELL Jk '`t— EMAIL � 4 F--( ( pPI ' wl
U2ffCV 3S 0
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
41,