HomeMy WebLinkAboutBLDG-17-003507 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
`.. ;tom:.,d' CITY Nw�ltn �� � MADATE )— cf- 7 PERMIT#/'���1�3 —06 5,�j'�
JOBSITE ADDRESS 1/ t4S.m4n isa 0 r- OWNERS NAME Se �r0m Met C
GOWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL 0----
PRINT
CLEARLY JEARLY NEW:E RENOVATION: ICJ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 I 1'
BOILER
BOOSTER ______I
CONVERSION BURNER
I
COOK STOVE
DIRECT VENT HEATER
DRYER 1
FIREPLACE
FRYOLATOR
FURNACE t
GENERATOR
GRILLE 1
INFRARED HEATER I
i
LABORATORY COCKS •
MAKEUP AIR UNIT r I
OVEN ,,1
POOL HEATER I,
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST _ _ - _ _ � ._ �`�
UNIT HEATER o
LINVENTED ROOM HEATER
WATER HEATER I
OTHER
1 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES Er 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 l
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
I
CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1
--. 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 1
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 I
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME K,.n 1, .34 LICENSE#I Ilot_9(04S--'ll SIGNATURE
MP I MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#!
COMPANY NAME n:Vt Pl—yt Ikon <14c - ADDRESS it 51q s O
CITY A-1 r,� cl., STATEAlit— ZIP t',r�� o'1'�` TEL Sc) z V 7 3 75
FAX CELL EMAIL ►21 we1 k /A/le j,� k%i. 1._,..,...4_
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
V Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
/ /d /7 FEE: $ PERMIT#
FLAN REVIEW NOTES