HomeMy WebLinkAboutBLDG-19-002688 . .. MASS CEILISETT UNIFORM APPLICATION FOR A P RM TO PERFORM GAS FITTING WORK
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MA DATE I l PERIv11T* b'- L 6 Q a
JOBSITE ADDRESS J1-)✓'' `-e <OWNER'S NAME 'i61 vt v'
OWNER.ADDRESS TEL FAX
^X,
TYPE PRINT
OCCUPANCY TYPE COMMERCIAL III EDUCATIONAL ❑ RESIDENTIAI J
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-F ssM 1 2 3 4 5 6 7 8 9 10 11 12 '13 14
BOILER —1
BOOSTER
CONVERSION BURNER,
COOK STOVE —__1
DIRECT VENT HEATER _
DRYER
I
FIREPLACE
FRYOLATOR —, I
FURNACE I
GENERATOR
GRILLE I
INFRARED HEATER " I
LABORATORY COCKS _y I
MAKEUP AIR UNIT
OVEN t- - i
POOL HEATER
1
ROOM/SPACE HEATER 420640' '
ROOF TOP UNIT
TEST -
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER I i
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE-a GE BY CHECKING TI-IE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY :0 OTHER TYPE INDEMNITY ❑ BOND ❑
I
OWNER'S INSURANCE WAIVER: I am aware that t' licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waive::this requirement.
i
CHECK ONE ONLY: OWNER ❑ AGENT ❑ I
`l SIGNATURE OF OWNER OR AGENT
.ii., I hereby certify that all of the details and information I have submitted or entered regarding this application are true curate to the best of my knowledge
`- and that all plumbing work and installations performed under the permit issued for this ap ' ' complian Pertinen ion of the
-'7*- Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
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PLUMBER-GASFITTER NAME LI EN SE#f f9/ Ki ATURE
MP I MGF❑ JP F❑ LPG! ❑ CORPORATION❑# PARTI ..'HIP❑ l LLC❑#
t%_� ADDRESS SS _ — I
COIv1PE{ICY IIA — u77 C
CITY ( cd aJL✓ .c STAT ZIP �, � 6 ( TEL 2 ,3 J � 1
FAX CELL EMAIL_
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES