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HomeMy WebLinkAboutBLDG-20-000438 MA SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ..fi o'J MA DATE a 5- PERMIT /,�C�(jr�d�Gb y� JOBSITE ADDRESS Z "k• G OWNERS NAME <a ec>N 0.1 GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONALRESIDENTIAL PRINT ❑ ❑ CLEARLY NEW:& RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO Si- APPLIANCES 1 FLOORS-t BSM 1 2 3 1 5 6 7 8 9 10 '11 12 13 14 BOILER —7 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER � FIREPLACE FRYOLATOR FURNACE GENERATOR. I I GRILLE INFRARED HEATER I LABORATORY COCKS • i MAKEUP AIR UNIT OVEN —� POOL HEATER I • 1/•�), ROOM/SPACE HEATER -‘ I ROOF TOP UNIT TEST .. • .__.. ) - UNIT HEATER , LINVENTED ROOM HEATER ' WATER HEATER1 1 OTHER . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES © N0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TI-IE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [' OTHER TYPE INDEMNITY ❑ BOND ❑ 1 • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachus-etas General Laws,and that my signature on this permit application waives this requirement. 1 CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT j •<I• 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 ith all Pertinent provision of the '`t t. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. I PLUMBER-GASFITTER NAME S c,.-' 6(Lp" ; i' e LICENSE#1606,6 SIGNATURE MP Imo' MGF❑ JP ❑ JGF❑ R LP/GI ❑ CORPORATION❑#i PARTI -',SHIP❑#t LLC❑# 6COMPANYY NAME '5 .-ft 10% ''i.S ADDRESS CITY 1 0 1I c•2e r ���, �1 J STATE i / ZIP O Z 6 TEL 5 TEL r�4\�Z 2 FAX CELL EMAIL 6le.r,, ( `i ey a 4 cs.,• -c' ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No PN7/ MT9 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 7 . k; i FEE: $ PERMIT it PLAN REVIEW NOTES