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HomeMy WebLinkAboutBLDG-18-000620 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - y CITY vq-k�� -.1OV'en J,'l* MA DATE It 7 PERMIT#/Y9/ /�'-1e0 JOBSITE ADDRESS `� tki. )NP. l 4 ilk t OWNER'S NAMES '1�iS fi'1 hZ\C1Q GOWNER ADDRESS SCWW TELL 7--412.) -SQ-23 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: (it RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO g APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER _ COOK STOVE _ _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN _ POOL HEATER _ ROOM I SPACE HEATER _ ROOF TOP UNIT TEST x° UNIT HEATER - tc2. 4(�'✓v UNVENTED ROOM HEATER -I _ WATER HEATER _ _ OTHER Li 7 n J r X _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES K] NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER TYPE INDEMNITY ❑ BOND El 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 c 'ance with-alt.pertinent pTvision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. +- k j--- PLUMBER-GASFITTER NAME-70civtb.P-09 fZ { LICENSE# CA 0 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI _ CORPORATION[ # PARTNERSHIP❑# LLC❑# A t1 � COMPANY NAME 4/11 F.�C.`ci ccO ADDRESS ) q 1 t y �;,>, 1, l LQ CITY --'ye,,-{v'N i S STATE WV) ZIP 0 2( J TEL c t E 1)S v ' ' FAX .•11 1-)S " 1 CELL `""' EMAIL i 4 /_ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No 77/ THIS APPLICATION SERVES AS THE PERMIT ❑ El-- FEE: $ PERMIT# 6 I( / / PLAN REVIEW NOTES