HomeMy WebLinkAboutBLDG-20-001407 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
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,6N CITY 1f �_C� MA DATE q - -
/(a� /9 PERMIT
JOBSITE ADDRESS /Y/ kreA OWNERS NAME(la t'
GOWNER ADDRESS ,q yvlf/ TEL FAX
TomE ` OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALPRINT
CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ N0yi _
APPLIANCES-1 FLOORS-+ BEM 1 2 3 4 5 6 7 5 9 10 11 12 13 14
BOILER ________—I
BOOSTER
I
CONVERSION BURNER
COOK STOVE J
DIRECT VENT HEATER
DRYER
I
FIREPLACE '
FRYOLATOR
I
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT I
OVEN i
POOL HEATER I
ROOM I SPACE HEATER I
ROOF TOP UNIT
TEST _..
UNIT HEATER -
UNVENTED ROOM HEATER
WATER HEATER �—
OTHER
_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YEN],NO ❑
I IF YYOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ i
i
• 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
'1:-.1-2, I hereby certify that all of the details and information I have submitted or entered regarding this application are true an accurate to the b/4 of my knowledge
`� and that all plumbing work and installations performed under the permit issued for this application will be in compli ce wit all P et rovision of the
Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
`1
PLUMBER-GASFITTER NAME LICENSE#3q7/ SIGNATURE
MP ❑ Me--iF 7 JP' JGF❑ LP F GI ❑ ORP RATION❑ PA , NE .SHIP i 41, LLC❑II
COMPANY NAI E vyrl,b/Ii/) /7 19 Y? ADDRESS O• c /x 3 /
CITY(JJ-. a(Nov)i at STATE ZIP ! 1 TEL 50 O 77 "5 1,
FAX CELL5 `: 714- O EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
/(e /w /'/i Q THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
?/c2 FEE: $ PERMIT ft
PLAN REVIEW NOTE•
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