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HomeMy WebLinkAboutBLDG-17-000789 r„ � MASSACHUSETTS UNIFORM APPLICATION FOR A. PERMIT TO PERFORM GAS FITTING WORK CITY i9 n ✓It o ce• 1-11 MA DATE r 'a of b PERMIT# b 17(/W7 er JOBSITE ADDRESS 12.' it t r 27r r OWNERS NAME •4'' e. OWNER ADDRESS P-It R n r Zy Fri c TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL®� PINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 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 UNVENTED ROOM HEATER WATER HEATER f OTHER bite()Icier- I INSURANCE COVERAGE I have a current liability insurance policy or it substantial equivalent which meets the requirements of NIGL.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 ❑ J 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(Naives 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 P vision th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME C ' S `/o 1 is LICENSE# g eo, SI RE 417 MP I MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION Q'#)- 32 - PARTNERSHIP 0# LLC❑# COMPANY NAME f.I-4 N 7)o y�� r� S N ADDRESS ID 0 i b CITY w ' Ny 4N'N t s h 0.A-4 STATE Pi ZIP ©2 fc) 'Z TEL 5 �' 72 - 13 FAX CELLA k 737 2. 9 C) EMAIL AUG 05 2[11h ir(�` ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I