HomeMy WebLinkAboutBLDG-16-005924 --,,,,T..,
` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j
,;,4L; CITY MA DATE V c3 JE, `t - l` PERMIT# n6 �6-Q6 7
'.4^tip,
JOBSITE ADDRESS�73 M,'l t vi .5- . OWNERS NAME MAA 6 ply .4 tL M Jkc,„F
GOWNER ADDRESS 111,24 e-. TEL,SOQ 7 71 "722 7FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0RENOVATION: _ REPLACEMENT: ❑ PLANS SUBMITTED: YES NO
I
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1A• l
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE ■
DIRECT VENT HEATER
DRYER 111 _
111111
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
��
GRILLEINFRAED HEATER 1111
_
LABORATORY COCKS 1
MAKEUP AIR UNIT
I
OVEN
POOL HEATER I
ROOM;SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER Al
UNVENTED ROOM HEATER _- 1E1
WATER HEATER11111
OTHER
INSURANCE COVERAGE / i
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO L���
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY 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 Gener'•I aims,and that my signature on this permit application jaives this requirement.
I_l1 CHECK ONE ONLY: OWNER ❑ AGENT
SIGNATURE OF OWNER OR AGENT
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
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#pZp (yam ., ' frfir__
SIGNATURE
MP❑ MGF❑ JP I2rJGF❑ LPG] ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑tt
` {
COMPANY NAME 'L i (- p i l wr b t 4 ADDRESS 1413 B y tCf i t l s-[ __
a
CITY �vA�GnP._T i<� STATE/YI7 ZIP c9/207 TEL 22/ 95--4c>35 I
FAX CELL EMAIL •
f
W N' Ji 'tier -17 =Ge. r
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
7b/71- 0/3 �l lei/ 3-1; 0 Yes too
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES