HomeMy WebLinkAboutBLDG-16-006304 MA SSACHLISETTS UNIFORM APPLICATION) FOR A PERMIT TO PERFORM GAS FITTING WORK
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.1�' CITY I., ,,p, ��vJi Z, MIS, DATE S /itt,( /A PERMIT# 1/ 6 �G�d6507
JOBSITE ADDRESS 1 V G0Ail_ 4_1 OWNER'S NAMEA/'✓Ge-/A o /)-71f I Cc
GOWNER ADDRESS 1C wi e ,1oL,n s7 G''`;.c7 ii.,tL'EL Gam! 7 %- AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL M.
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:K PLANS SUBMITTED: YES❑ NO❑
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APPLIANCES FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 '11 12 '13 14-
BOILER / �—
BOOSTER __
CONVERSION BURNER -- _
COOK STOVE ❑
DIRECT VENT HEATER
11111
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER �10 —!
LABORATORY COCKS il1 MAKEUP AIR UNIT 1
OVEN
POOL HEATER
ROOM;SPACE HEATER
ROOF �TOP UNIT
TEST
UNIT HEATER
UN VENTED ROOM HEATER 111111
❑ _� ❑
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 ji
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. l
CHECK ONE ONLY: OWNER t 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 t ue and accurate to . est o my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co liance with all Pe e t o ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFIT'IER NAME LICENSE# ici tic-_ `% ' SIGNATURE — I
MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME D A-1,41• L,.'.: /)(u ram(J' r i ADDRESS --2S b4-1��`ic L.-,l ioG( -r% ('J1 t
si"4--/ 04174
CITY l x� Iv ) STATE �L C � 6`� � ZIP 'Z l --)1 TEL -3--t�1 --5 1 - F'/‘,_..4‘,_..4FAX CELL EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL.INSPECTION NOTES
IP&iL Co/ oh G Q 0.00 Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES