HomeMy WebLinkAboutBLDG-17-000362 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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,,;firm=,d CITY yiq.�FvkCAA- MA DATE 7— /9- /d PERMIT# I;i. /�- 7�?��L=icy ////4� / � 00a y
JOBSITE ADDRESS /6 KE( OWNER'S NAME /l 0(ft- q. //P�'cy�
OWNER ADDRESS :141:v /lr+ L TEL FAX /
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [�� PLANS SUBMITTED: YES❑ NO❑
APPLIANCES Tl FLOORS-4 BPM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I,
DIRECT VENT HEATER
DRYER, j
FIREPLACE
I
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER —1
LABORATORY COCKS I
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER '
ROOF TOP UNIT
TEST
UNIT HEATER
(INVENTED ROOM HEATER
WATER HEATER — )
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES Ef NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COOVERACE 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 General Laws,and that my signature on this permit application waives this requirement.
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 compliant all Pe�ent o ' on of the
Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# , SIGNATURE
MP❑ MGF❑ JP[ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME r?occ Ct� (� ADDRESS ►9 Cs0Id.t i v 7
CITY /die-WIC(Ak(A_ STATE r 4 A ZIP C'9.6d4 R ETl`1` 7 317/5-
FAX CELL EMAIL *AO
9 O16
lee BUILDING i;Af -0 4(1)
By
•
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