HomeMy WebLinkAboutBLDG-18-007370 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMET TO PERFORM GAS FITTING WORK
k7.R CITY 4j-44,(A-"f'4 MA DATE 6. /_ / PERMIT#1Ob^1,F 7o7O
JOBSITE ADDRESS Y Cs. 47 ,4 Ste, OWNERS NAME A 4.-)-, 6
GOWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL ® "--- EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: V PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—F BSM 1 2 3 1 5 6 7 8 9 10 11 12 '13 14
BOILER
I
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER --i
_
DRYER
_
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT 1
OVEN .)— -
I,
POOL HEATER
ROOM!SPACE HEATER I
ROOF TOP UNIT
I
TEST
UNIT HEATER
UNVENTED ROOM HEATER T 1
WATER HEATER
OTHER 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1p ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY t 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.
1
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 tr ccurate to the b f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co I' nce ith all in t ovisi of the
Massachusetts State Plumbing Cod Chapter.142 f e General Laws. '
Loer
PLUMBER-GASFITTER NAME R`/A "t o;.- LICENSE# SIGNATURE
MP ❑ MGF❑ JP 12 -71GF❑ LPGI/❑ CORPORATION❑# PARTNERSHIP} El# LLC❑MPANY NAME H� o�vt.e- Pi" /7� ADDRESS /°(6 LYv-� e h ti Al,A, �
CITY /742 r �-(C 4 STATE %//19 -ZIP Od"U Y ) TEL i I
FAX CELL EMAIL ,Ca (pc/ #0 6 ® 4
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL,INSPECTION NOTEq
Yee No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES