HomeMy WebLinkAboutBLDG-18-001230 ,'' MAS SACHUSETTS UNIFORMAPPLiCATiON FOR A PERMIT TO PERFORM GAS FITTING WORK
` t 0' CITY yA / ®(1 \ MA DATE PFRiv1IT tt /)6 AC'00/Ea
���� JOBSITTE ADDRESS S Y"\ aF%"` /` IM ER'S NAME Nl(3C- LL V19 LLG
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OWNER ADDRESS S 2. 2_ VV I &4,, TEL TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL RV EDUCATIONAL ❑ RESIDENTIAL❑
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A �` NEW:1727 RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
'PPLIANCES 4 FLOORS--+ Bsivi 1 2 3 4 5 6 7 8 9 1Q VI 12 13 1!
BOILER
BOOSTER I
CONVERSION BURNER —
COOK STOVE
DIRECT VENT HEATER =
3 DRYER
V FIREPLACE
L. FRYOLATOR
1, FURNACE
GENERATOR.
GRILLE• I
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN .;i I ; i,'
POOL HEATER
II
ROOM/SPACE HEATER
ROOF TOP UNIT 'V I s7
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
I,.
OTHER if-pt Q.+�- IIII I
1
INSURANCE COVERAGE �,�/
I have a current liability insurance pulley or its substantial equivalent v'hich meets the requirements of MU.Ch.142 YES U NO E
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE.APPROPRIATE BOX BELOW
LIABILETY 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 ❑
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 comp' .with all Peryent rov ' of the
Massachusetts State Plumbing Code and Chapter 1h2 of the General Laws. de471,Vae
PLUMBER-GASFITTER NAME LICENSE 3.26
2$ ' SIGNATURE
MP ❑ MGF❑ JP 13<[GF❑ LPGI ❑ CORPORATION❑>rF PARTNERSHIP❑# LLC❑ti
COMPANY NAME ADDRESS 4 9 (7-61-pi-Gvi-"N- S4v-.1.� VQoc0c-4
CITY ' yete"--44rU-71/-- STATE N4 ZIP (la 66ff TEL ,51(7g 360 37/9
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL t IOTE
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT(I
PLAN REVIEW NOTES