HomeMy WebLinkAboutBLDG-24-491 t ,s1 ., MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM GAS FITTING WORK
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--^,�(� MA DATE PPERMIT* 's?t 06-2y-c1yi
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JOBSITE ADDRESS y 0,jej--- OWNER'S NAME
GOWNER ADDRESS �OZ TEL 5 S ` FAX
TYPE OR ——�
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT.kit
APPLIANCES Z FLOORS-. BEM 6.4 • -
PLANSSUBMITTED:YES 0 N0
BOILER 13 14
BOOSTER
CONVERSION BURNER,
COOK STOVE VENT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR l
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER MINI
ROOF TOP UNIT
TEST ..
Et
UNIT HEATER - --
VENTED ROOM HEATER ! ' i' gii
WATER
OTHER HEATER ' c
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES It NO 0
I F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TIE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 OTHER TYPE INDEMNITY 0 BOND 0
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 0
J 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
ssl' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME /LICENSE# SIGNATURE
MP 0 MGF 0 .^JPP ig JGF 0 PGI 0 rCORRPORATION❑tt PARTNERSHIP❑# LLC 0#
COMPANY NAME 11 Il rj P/ I1 ADDRESS 37 _R L i '/1 4e//(4{°
CITY q ..1 I t 5- STATE ZIP 0 e e: ',// TEL 77Y wyd 9/ZL
FAX CELL EMAIL
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JWUGTI GAS INSPECTAON NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: a PERMIT#
PLAN REVIEW NOTES