HomeMy WebLinkAboutBLDG-18-003784 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
, CITY Yil.R.
m 0 L(, MA DATE I- - i✓ Q /f 7`.. �-, PERMIT# �'�-60 hj�/
JOBSITE ADDRESS (Q "5 ( • �N U S� Way OWNERS NAME
OWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:Z( PLANS SUBMITTED: YES❑ NQ
APPLIANCES 7l FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 111 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER.
COOK STOVE
DIRECT VENT HEATER 1
1
DRYER I
FIREPLACE I
FRYOLATOR
FURNACE —r—
GENERATOR
GRILLE j
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT I
.
OVEN
POOL HEATER • {
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER I I
WATER HEATER
es-Toe.
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES ] NO ❑
I 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 ❑
•--, 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 compli ce with all Pe ' ent pro ' ' n of th
Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
LE)
PLUMBER-GASFITTER NAME LICENSE# SIGNAT E
MP<-MGF❑ JP�JGF❑ LPGI ❑ CORPORATION Kit 'SiC, PARTNERSHIP❑# LLC❑##,
COMPANY NAME ��G CT //U6 ) t iA1 — lri'ADDRESS 3Uq/.cc/g- ' �, l/�
CITY �14�/ flail STATE 4/4. ZIP b 2/1 TEL .Sd? '727-al-o0/
FAX CE15-642,'d6 'go EMAIL 30 t;; 'V'/C,C
Leif
•
ROUGH GAS INSPECTION NOTES THIS PAGE FOR.INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yee No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT ft
PLAN REVIEW NOTES