HomeMy WebLinkAboutBLDG-19-005539 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
n rn_,G� CITY L4c,( N -t -I O ) MA DATE 3-ZZ-1 / PERMIT#/3/9b/?
JOBSITE ADDRESS (9,1— l)tr^ -L4-x±r-\ h 13 - OWNERS NAME P0.1]- —
GOWNER ADDRESS S714 ivt" - • TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ I
APPLIANCES• FLOORS-4: BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _;
BOOSTER —j
CONVERSION BURNERN 111..,���_._ I
COOK STOVEf' r
I
DIRECT VENT HEATER ■ ■ 1111111 _
DRYER
FIREPLACE a I I ' '
FRYOLATOR —
FURNACE I IGENERATOR. 1
GRILLE
❑ ❑ ❑ ❑ ❑ ❑ ■
INFRARED HEATER
COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM;SPACE HEATER _
ROOF TOP UNIT A
TEST _ .
11111
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements at NIOL.Ch.142 YES RHO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG•EY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ( OTHER TYPE INDEMNITY ❑ BOND ❑
I
• 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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CHECK ONE ONLY: OWNER ❑ AGENT ❑
`` SIGNATURE OF OWNER OR AGENT i
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 I
and that all plumbing work and installations performed under the permit issued for this application will be in c • a with all Pertinent provision of the
• Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMB ER-GASFITTER NAME LICENSE# /o SIG URE
MP IVIGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑#i PARTNERSHIP❑# LLC❑# I
COMPANY NAME P, 6\j745 Phi/h`J,n S ADDRESS 12- Fyn r1 ,p,o"7Cl
CITY /1' ' 5 i1'74 STAMP.?A ZIP d 24 0 TEL Pk'3rrc-2-i- ._--
FAX CELL far-319-ayo6 EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION GTION NGTEc'
Q J� THIS APPLICATION SERV1 S P1 THE PERib11T ❑ ❑
CCl1�� V
,- zr FEE: $ PERMIT(�
'� - PLAN REVIEW NOTES
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