HomeMy WebLinkAboutBLDG-17-002027 2Fx
MASSACHUSETTS UNIFORM APPLICATION FOR A. PERMIT TO PERFORM GAS FITTING WORK
� li1_ CITY 4/ ,/4a. 1) MA DATE /0 l9 /' PERMIT#fr-a,'s/7-6V470.17
JOBSITE ADDRESS U/V! r /o 81���� `i1� Re'�/t�P� � �(/.js�,�t;POI�,�iV>=R'S NAME�c ,elJ� 0 /c
OWNER ADDRESS/ >¢ )t�c /?0 TEL P 744 'Roo FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES T FLOORS—. BSM 1 2 3 4 5 6 7 s 9 10 11 12 '13 I 1'
BOILER I
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR.
GRILLE '
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN lI
T POOL HEATER 1
ROOM I SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER j I
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent wh. efts the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAC . 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.
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 Pertinent rovision of the
I, , Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
til PLUMBER-GASFITTER NAME LICENSE'/`7p?ey SIGNAT RE
MP❑ MGF❑ JP, GF❑ LPG' fl CORPORATION ❑ F PARTNERSHIP I_];<f LLC #:❑
/
COMPANY NAME ' //C,j,eit L /_ s`�O�q ADDRESS ton ,P S c- � �? -'-
c
CITY 6c/• -gGZ • STATE "1)(19 ZIP Oe i '� Z- o/c ee
FAX CELL STG C 9e 2 - U!G i EMAIL i
ACT 19 201h
l DEPART 0-`'t)
By _ _/"i
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
pti/ - 6 01' uQ G' /D/ j1l to yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
f LAN REVIEW NOTES