HomeMy WebLinkAboutBLDG-18-002306 Ci Oa)
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY_ /f c S MO 4 MA DATE Oa- ( ZO l 7 PERMIT#/G.l/�L"- efi'-C�7o7.��
JOBSITE ADDRESS ((9 ` - l�1t)i OWNER'S NAME V iP[ewt
GOWNER ADDRESS TEL_ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL MV
PRINT EDUCATIONAL ❑ RESIDENTIAL RK
CLEARLY NEW: E RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES 11 \10❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 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/SPACE HEATER
ROOF TOP UNIT ( 1 } -- M&ve Rowe (
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES e'', NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L 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 E.
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 th t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co is th all Fe i provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME William Lane, Sr. LICENSE# 8318 SI AT��
MP❑ MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION'',# 3277 PARTNERSHIP❑# LLC❑#
COMPANY NAME Superior Plumbing, Inc. ADDRESS 356 University Ave
CITY_Westwood STATE MA ZIP 02090 TEL 781-461-1541
FAX 781-461-2971 CELL EMAIL
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