HomeMy WebLinkAboutBLDG-17-001159 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CIT`( MA DATE —a- -16 PF tMIT#D44b -/-7-9
JOB SIT EADD ._SS 1G tiP"11.5c" L.s4AL OWNERS NAM 3 1- a -i,?. .
OWNER ADDRESS rS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALPRINT
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CLEARLY NEW:❑ RENOVATION: [ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BEM 1 2 3 4 5 6 7 8 9 10 111 12 13 J 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
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER _
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INSURANCE COVERAGE �, /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU.Ch.142 YES -�l'IO ❑
I II'i'OU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V 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 compliance with all in pr ision of the
Massachusetts State Plumbing Code and Chapt42 of the General Laws.
PLUMBER-GASFITTER NAME C /iie2k-414 LICENSE "]/ SIGNATURE
MP T"f MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME MIC7%(' AL-7Ia1 I.4L9 ADDRESS ! r (3. C &-.
CITY �1. .4,_s STATE _ ZIP ?
FAX CELL 7?C <C)1Q EMAIL
Z/zl .
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
mfil,L )? 9//o`* Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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