HomeMy WebLinkAboutBLDG-20-002017 -_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�J'' \ i q go/7 I e.�:t>r ; CITY G��rc�(k.�s-� 1�4A DATE �� \� -� 1 PERMIT* �/L "�Z� �
JOBSITE ADDRESS 5 a Rai gp^ OWNER'S NAME `a• sec
GOWNER ADDRESS Sc-^.--"\ TEL b -5/9-3I1 1 FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL VV
PRINT
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT:r PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-+ BCM 1 2 3 l 5 6 7 8 9 10 11 12 13 11
BOILER /
---7
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER I_____,
DRYER. 1
FIREPLACE _
_
FRYOLATOR •
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _ 11
OVEN
POOL HEATER r _
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST _.
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER I I
1
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POL6C d?en OTHER TYPE INDEMNITY ❑ BOND ❑
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
Ni-, 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 in ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#t 'I ` RE
MR ❑ MGF❑ J 6. JGF❑ LPGI❑ CORPORATION❑ F PARTNERSHIP❑`�# tic❑
COMPANY NAME (*R<-- -Q \�`'A ADDRESS `�J v
A
CITY CarAC2CV \k STATE(/VV y ZIPca(9�� TEL
FAX _ CELL �37_S3I(& EMAIL"A4\ G(�-0--(J�.>.--- 19 5_r cov---,
G ; '°' - & D 4400 = iZP X Z---0e64-
ROUGH GAS INSPECTION P4OTRS THIS PAGE FOR INSPECTOR USE OI{LY FINAL INSPECTION NOTES
Yes Nt.)
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT tt
PLAN REVIEW NOTES