HomeMy WebLinkAboutBLDG-18-004452 MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM GAS FITTING WORK
,; ;�,L_ CITY( $O( t�y. 71 MA DATE Z- , ` PERMIT# ���/' �.-'�► d� s
a.v JOBSITE ADDRESS 2 7 At-A ►O OWNER'S N•AME2 r:h`"' -► j ol-v
GOWNER ADDRESS TEL TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL` _
PRINT
CLEARLY NEW. RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ 10
APPLIANCES 1 FLOORS-4. BSM 1 2 3 4 5 6 7 8 9 10 11 12 •13 14 I
BOILER --I
BOOSTER —I
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER >
DRYER , '
FIREPLACE '
FRYOLATOR
FURNACE I/
GENERATOR / I
GRILLE i a
INFRARED HEATER �I
LABORATORY COCKS
MAKEUP AIR UNIT I
OVEN 1
POOL HE?,TER —- I
ROOM;SPACE HEATER R = �i E D
ROOF TOP UNIT '
TEST FEB7 ,
UNIT HEATER
VENTED ROOM HEATER -
WATER HEATER 1'
1_1
UN _DIN D ��EPARTMENT
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YESdd 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.
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`i CHECK ONE ONLY: OWNER ❑ AGENT ❑ i
J
SIGNATURE OF OWNER OR AGENT
'24..., I hereby certify that all of the details and information I have submitted or entered regarding this application are true and irate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn liance all Pertinent provision of the
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Massachusetts State Plumbing Code and Chapter•142 of the General Laws.
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PLUMBER-GASFITTER NAMES1T_PI- LICENSE#18S13)(41 SIGNATURE
MP ❑ MGF❑ JP'i JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME --A--1 jce"\I P-I-}-t ADDRESS 5 L4-4•
CITY ZP'CT ,4"°`--, % ''E STATE ZIP TEL TEL —5 H ( I
FAX CELL ' SZ S--t1 EMAIL —6.65 1 0 l'-( /� 11c-Ftr i- tivZ„,.-t
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
77/ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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/r FEE: $ PERMIT ft •
PLAN REVIEW NOTES
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