HomeMy WebLinkAboutBLDG-18-00618 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
nP d' CITY )/for MC' MA DATE g-/V/ 7 PERMIT#/ 6''/ UOO the
JOBSITE ADDRESS 51 SA rrt-G 0(,0 6'coo K-R. OWNER'S NAME Lvi r (._:(WAR
1)
OWNER ADDRESS cr.A TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALV
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 1
APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 'li 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/SPACE HEATER Al ifj 0 1
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED 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
il-
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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 ❑ I
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 compliance with er nt provislgn of the
LE) Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#Mg3�q SIGNATUEE
MP ki MGF❑ JP JGF❑ LPGI ❑ CORPORATION VF ','OS` PARTNERSHIP #!:
y ❑# LLC❑ )
COMPANY NAME 1� L� C . 7 T�b'�'� �•t',✓(�
� -1 ADORES,, 2°CITY Yn1 410 aj STATE I4 ZIP D C .7/ TEL
FAX C ),"" ?al tW/`S EMAIL 7 m i y2 Y/c , nMIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT tt
PLAN REVIEW NOTES