HomeMy WebLinkAboutBLDG-19-000200 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`,,LP CITY 4 r �Ij MA DATE /y / B. PERMIT* U����G����-.•t r•
JOESITE,ADDRESS [ 9 ,L A(u/4 S C cf ii-a r- OWNERS NAME A r�i,—ru w
GOWNER ADDRESS TEL FAX
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TYPE OROCCUPANCY TYPE COMMERCIAL tC1V EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO ❑ 1
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APPLIANCES FLOORS- 6SM 1 2 3 1 5 6 7 8 9 10 11 12 '13 14
BOILER I
BOOSTER I
I
CONVERSION BURNER _
COOK STOVE I i
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYC)LATOR
FURNACE
GENERATOR
GRILLE '
INFRARED HEATER I
LABORATORY COCKS ,ia
MAKEUP AIR UNIT '
OVEN JJi
POOL HEATER
ROOM 1 SPACE HEATER I
ROOF TOP UNIT
TEST ---
A 1
UNIT HEATER
UI4VENTED ROOM HEATER
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of 1I L.Ch.142 YES U' ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Cl/ OTHER TYPE INDEMNITY ❑ BOND ❑ I
• 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
1
v CHECK ONE ONLY: OWNER ❑ AGENT ❑
•� SIGNATURE OF OWNER OR AGENT j
`i•• I hereby certify that all of the details and information I have submitted or entered regarding this application are true a 2 curate to the best y knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in corn is ce •th all Pe ' ' ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. €
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PLUMBER-GASFITTER NAME 0 a v r al 77/°(,-(14LICENSE# 5 ) 0 i-- SIG AT RE
MP ❑ MGF❑ JP E1JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# 1
COMPANY NAME , d Plc / ADDRESS (o/ Qv-e-e„ A Elt I
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CITY Alet /^wl G 4 STATE/744_ . ZIP d 6 S_ TEL C'd 3-- ,)--Q �.- `{ (I
FAX CELL EMAIL .0c.y;d /I ,,,4 6 g
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES