HomeMy WebLinkAboutBLDG-18-002133 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`. ,ks___.,6 CIT( \I +rb. MA DATE 10- �,d 4)0;7 PERMIT#&-v-lfT-/Z-6, A/
JOBSITE ADDRESS C( c De l -u'+ L. C OWNERS NAME 1"" U L.,
GOWNER ADDRESS ic1)(n Mom' A/� CAL. TEL FAX
TYPE OR
T OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL X
PRIN
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO ❑ I
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APPLIANCES- FLOORS- BEN 1 ? 3 4 5 6 ° 9 10 I'I 1? 13 1 f
BOILER
BOOSTER j
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER ( l
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR T _______IGRILLE ' i
' INFRARED HEATER -_I
LABORATORY COCKS - i
MAKEUP AIR UNIT
OVEN ____1
POOL HEATER 4
7n
ROOM/SPACE HEATER ;i i - ' I
ROOF TOP UNIT I
I
TEST
UNIT HEATER /> � a a"�
UNVENTED ROOM HEATER �(• c� i
WATER HEATER
OTHER �� c,T�,,-;SIi�E-)
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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 YES A NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY N OTHER TYPE INDEMNITY ❑ BOND ❑
I
OVtiNER'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 ❑ Ii
SIGNATURE OF OWNER OR AGENT 3
•: 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
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P nent provision of the
Massachusetts State Plumbing Code and Chapter 142f the
General Laws.
PLUMBER-GASFITTER NAME LICENSE# 3,.9.ati
`IGNATURE
MP ❑ MGF n JP yj JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑
COMPANY NAME 'APE P l:44te- r, (-F 1 ( ADDRESS ^13 d'b OX O�
CITY U.),.), biY4A rZ STATE 1�` - ZIP G d-t467. TEL 50 73 !{�
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FAX CELL EMAIL k C L fa LL -5 �1 ,(4 OVVt
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑(7r.•
❑
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FEE: $ PERMIT PLAN REVIEW NOTES
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