HomeMy WebLinkAboutBLDG-17-003800 r '` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`,����,s, CITY MA DATE PERMIT
JOBSITE ADDRESS 5--,2 3 \ 0 ti vc OWNERS NAME De "c- ' igc:,--1/7
GOWNER ADDRESS I�"' 5T_ TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL E
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 0"--- PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-* BSM 1 2 3 4 5 6 7 s 9 10 11 12 13 I 14
BOILER
BOOSTER —�
CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER ,
DRYER
FIREPLACE '
FRYOLATOR
FURNACE
GENERATOR I
GRILLE 1
INFRARED HEATER
LABORATORY COCKS _.1 AN t ,-s ) I
MAKEUP AIR UNIT c/4 �� a(pa !J U i
k/f OVEN JJ
POOL HEATER I
ROOM I SPACE HEATER I
ROOF TOP UNIT - _
TEST . _ .
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER - Ca-tho '3aik w/14 B I
1
1
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 1-(6/0t
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑---/' OTHER TYPE INDEMNITY ❑ BOND ❑ 1
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the l
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
i
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT I
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 all Pertinent provision of the 1
Lt) Massachusetts State Plumbing Code and Chapter*142 of the General Laws.
PLUMBER-GASFITTER NAME s {f e _1411 LICENSE#€j3,gsl SIGNATURE
MP i 4GF E JP ❑ JGF❑ LPGI ❑ CORPORATION af 3/a'y PARTNERSHIP❑## LLC❑#!
COMPANY NAME ?cr51- l ) I v-i44' ""c' ADDRESS .7 S'' ` 4, i'✓ ...,
CITY '6A-/ STATE <'7M ZIP oa33° TEL ‘565- �66 3020 61
FAX -9-2*e-- CELL 576- 6 V53-1 EMAIL rLPkn A-A'-f it,-44,d'l ,tee e '/C-U1.7tYv•
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