HomeMy WebLinkAboutBLDG-17-001534 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
el yti7ntO ) 0 i4 MA DATE 71( 16 E —ev
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JOBSITE ADDRESS 9,15-- -11-1C13X/b1? $l . OWNER'S NAME W-kiG
OWNER ADDRESS TEL� I' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: V PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOORS-4 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 .- 5-3rO
ROOM/SPACE HEATER
ROOF TOP UNIT )
TEST It V
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 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g 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 accurate to e f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp e with all min ision of the
a, , Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#3961 ATURE
MP❑ MGF❑ JP❑ JGF 1LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMFAIV I�IAME P�%���i greir—,Qk ADDRESSp2, �JJ �l
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CITY ( nit) t STATE �/ ZIP V' Ip 6 TEL -- /u'a.
FAX 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