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HomeMy WebLinkAboutBLDG-18-002155 .'` IASSA.CHUSETTS UNIFORM APPLICATION FOR A PERMIT T PERFORM GAS FITTING WORK I t ,i.a, `�y �-'G�-(C�t�7'f-/ WPERMITtt / i2�/i-oOa/s3- ` .k,—_ , CIT( . DATE j� _; JOBSITE ADDRESS 7-�l,I�J�1�� OWNERS NAME OWNER ADDRESS -'",v` -6 TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL N--'----- P]II' T CLEARLY NEW:❑ RENOVATION: EPLACEMENT: [l./.---- PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-I- FLOORS—F BSM 1 2 3 4 5 6 7 8 9 10 111 12 '13 14 BOILER BOOSTER CONVERSION E3URNEP, COOK STOVE DIRECT VENT HEATER —� DRYER1)...< ' ! FIREPLACE FRYC)LATOR FURNACE 1.------.. GENERATOR GRILLE ' INFRARED HEATER I LABORATORYCOCKS ' I - i MAKEUP AIR UNIT i ! OVEN ,j ' J i POOL HEATER P ROOM/SPACE HEATER I ROOF TOP UNIT ' TEST . . . UNIT HEATER LINVENTED ROOM HEATER I WATER HEATER 3 OTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial eguivale a ich meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA . Y 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. I, . I CHECK ONE ONLY: OWNER ❑ AGENT ❑ 11 SIGNATURE OF OWNER OR AGENT j '"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 compliance ' II Pertinent provision of the Massachusetts State Plumbing Code and Chapter.142 of the General Laws. LIJ PLUMBER-GAS fE-R NAVE LICENSE# J SIGNATURE MP l MC4F JP JGF n<DGI ❑ CORPORATION❑#F PARTNERSHIP E# LLC❑# COMPANY I\IAIvIE 6 / ) - ( P14-H ADDRESS 25 - 'lau V i b. CITY Y/412-MO 1)'rid STATE 14'0/ ZIP ©2 75 T�O3 S FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL,INSPECTION NOTES Yes No C/IL /4 C G� THI APPLICATION SERVES THE PERMIT ❑ ❑ / V/i(//7 FEE: $ PERMIT# PLAN REVIEW NOTES •