Loading...
HomeMy WebLinkAboutBLDG-16-007043 ss 01A0) (o/Al ,, MASSACHUSETTS UNIFORM APPLICATION FOR A P RNIIT T PERFORM GAS FITTING WORK `` ' 1" CITY )i-x o V ( i- MA DATE 2- P MIT# fae j6-097L6T JOBSITE ADDRESS / 3 , I Z.5 0 NER'S NAME I 51 /-IL /2i , GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL© ------- EDUCATIONAL RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 j 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLA.TOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS 1 MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER { UNVENTED ROOM HEATER WATER HEATER . y OTHER — 5e c 4_, I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND El 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. CHECK ONE ONLY: OWNER ❑ AGENT El 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER- FITTER ME LICENSE# J �j�1� --q-k m SIGNATURE MP MGF JP JGF❑ LPG] ❑ ORPOP TION ❑# / PARTNERSHIP❑# LLC # F1TJ1$Ai_ i r COMPANYNAMADDRESS CITY Yfi-/Pfrn V ( STATE M/'-►-ZIP 0 2 73 Trc-- - -..�- FAX CELL ���TIVIAIL 1 Y JUN 23 2016 1 DI PARTMENT 4 l - y ...„ ...... ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES ctfiuN,-Y Ole UP Yes No THIS APPLICATION AS THE PERMIT ❑ ❑ Rol-- 6.45 eke .7/ FEE: $ - PERMIT# PLAN REVIEW NOTES