HomeMy WebLinkAboutBLDG-16-005297 \ r
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mAsSACHNSETTG UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY }~�c«^''u« L���, MA DATE `��~ -o;2 � mrl
, � PERN|T# -00 5,2
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JOBS|TEADDRESS / ° w ~ �7^/ �� m OVVNER'SNAME >/�'+/�~�u~~°
OVVNERAOOREGS '��`�`/ V TEL FAX
TYPE OR �_�^
OCCUPANCY TYPE 'COMMERCIAL EDUCATIONAL [] RESIDENTIAL El
PRINT ��
CLEARLY
NEW: Fl RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES NOF]
APPLIANCES-1 FLOORS— aSm 1 2 3 4 5 V 7 D 9 10 11 12 13 14
BOILER
BOOSTER |
CONVERSION BURNER '
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE �
FRYOLATOR
FURNACE '
GENERATOR
GRILLE
INFRARED HEATER
' LA8DRATORYCOCKS �
MAKEUP AIR UNIT
OVEN
|
POOL HEATER
/
ROOM/SPACE HEAT ER
ROOF TOP UNIT
TEST y
UNIT HEATER
UNVENTED ROOM HEATER |
WATER HEATER
OTHER i
|
INSURANCE COVERAGE /
|have o current|idd|by insurance policy or its substantial equivalent which meets the requirements ofM8L Ch.142 YES [��N� E]
||F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW .
LIABILITY INSURANCE POL| OTHER TYPE INDEMNITY 71 BOND
OWNER'S INSURANCE WAIVER:I arn 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.
CHECK ONE ONLY: OWNER F-1 AGENT E]
SIGNATURE OF OWNER ORAGENT
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 nfmyknowledge
and that all plumbing work and installations performed under the permit issued for this application will be inn with allPertinent ofthe
Massachusetts State Plumbing Code and ox ' ,'1*ecxmaoonom|Lavm.
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PLUM8ER'8ASF|TTERNAME � '��-x ��/ ���0��[/ L|CENSE# /���� �
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MP17 MGF0 JPF-1 J8F[] LPG| CORPORATION 21r' 31X/� PARTNERSHIP F�# LLC[:1#
COMPANY NAME ?6td-p"'4 \ /u�=w^�� -+`�'- ADDRESS'
CITY STATE "x ZIP 60330 TEL 501- 5+6u' 320/7
FAX ��� CELL �� EMAIL �/~�^� ``� 4!!
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/� ROUGH GAS INSPECTION NOTES) THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
IC k 6 �J'2/ ��" /� ///,6 Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES