HomeMy WebLinkAboutBLDG-17-005732 MASSAC USETTS UNIFORM PPL.ICATIOt4 FOR A PE MET TO PERFORM GAS FITTING WORK
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�`4L k=6 CITY l'1'� MA DAT PERMIT#I'f �"Ot5 6 5
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JOBSITE AD .ESS a- ' NAME /f/ �'�
OWNER ADDRESS
i? TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 11/
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: IV PLANS SUBMITTED: YES❑ NO❑
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APPLIANCES 1 FLOORS--F BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 ■
BOOSTER —j
CONVERSION BURNER, ■
COOK STOVE
DIRECT VENT HEATER —_
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
y• INFRARED HEATER ■ ■
LABORATORY COCKS
MAKEUP AIR UNIT ��
OVEN ,, "
POOL HEATER III 0/ 701
\ ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
1k WATER HEATER
OTHER
1
INSURANCE COVERAGE
i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.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 ❑
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 14.2 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
J 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 accurst o th st of my knowledge
`— and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit I e ' t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#t ''''iv GNATURE
MP ❑ MGF LO' JP ❑�JGFn❑ LPGI❑ CORPORATION❑#i ` PARTNERSHIP❑# LLC❑#
COMPANY NAME fj„ E. J,o1 /n , ,v S ADDRESS /—' O• UX /t'4/3
CITY (SeAte'/411/6 jnc A r 11' STATE Ili ZIP (9 z" 7 ' TEL_T?)9,° 7i d C!(}'.
FAX ✓ CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR OR USE ONLY
FINAL INSPECTION NG1'ES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: PERMIT tt
PLAIN REVIEW NOTES / 4 TL S Q-Ali