HomeMy WebLinkAboutBLDG-25-375 5Z MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r MA. DATE J 1'IU JO O PE MIT# QLO G!Zs- 3-7'r CITY: �� J /
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JOBSITE ADDRESS: 1J '�t'P OWNER'S NAME.' r- SCqM)u A
GOWNER ADDRESS: TEL: FAX:
TYPE OR 'OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NOS
APPLIANCESI FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR _
GRILLE
1.1 INFRARED HEATER t1 LABORATORY COCK 1 1\ C
MAKEUP AIR UNIT --
OVEN
POOL HEATER a l�f I Q5.
ROOM I SPACE HEATER !�
J ROOF TOP UNIT tit NT
T TEST gDICi1N�DCS'P _ _
Z UNIT HEATER c+y -- --j
iL UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE �(,
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES pl NO❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ' 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true d accurate to best of my
Knowledge end that all plumbing work and installations performed u der the permit issued for this application will In co a th all Pertinent
provision of the Massachusetts Stet Plumbing Code end hepter 42 of the General Laws.
PLUMBERG4SFITTERNA//ME: \C' I LICENSE#31`J11 ATURE
COMP NAME: 'n{'�'' I lU �� DRESS:
CITY: kW(CV\ STATE: ZIP:(13.617 FAX
TEL: CELL: '? 72 yS EMAIL:
MASTER 0 JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
Eh7/3/4. ADIXLeSS:
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES