HomeMy WebLinkAboutBLDG-24-46 10 --- MA/SSACHUS_E TTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY l i f s,✓ l 42 MA, DATE I I')-.-�� PERMIT# B4-06 2 1- LI N
JOBSITE ADDRESS I Li 1 PI'. -4-N OWNER'S NAMEG L 5
OWNER ADDRESS TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL P.'.
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[g' PLANS SUBMITTED:YES 0 NO❑
APPLIANCES 7 FLOORS-. OEM 1 2 3 4 5 6 7 0 9 10 11 12 13 1"
BOILER
BOOSTER
CONVERSION BURNER - -
COOK STOVE .
DIRECT VENT HEATER -
DRYER
FIREPLACE
FRYOLATOR -
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS -
MAKEUP AIR UNIT
OVEN
POOL HEATER • _R "1 C F I V r ID
ROOM I SPACE HEATER
ROOF TOP UNIT1.
TEST I12 2024 3 T_
UNIT HEATER
UtdVEIJTED ROOM HEATER u,PAR �
BUI LC ING MEN1
WATER HEATER 3r
OTHER
H
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent whichmeets the requirements of MU..Ch.142 YES pr NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ 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 ❑ AGENT ❑
J SIGNATURE OF OWNER OR AGENT
si,,, 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 ail Pertinent provision of the
sc. Massachusetts State Plumbing Code and ChaLi) pter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# )__6C Q)-- SIGNATURE
MP❑ MGF❑ JP ni JGF 0 LPGI 0 CORPORATION// LL
❑4 PARTNERSHIP❑# C❑#
COMPANY NAME fir,S 1, /- 4 ADDRESS 'It" Raid l S t /, ,-i- S
CITY 1340,:_. N-. STATE 174 ZIP 'n PO,1-- TEL Sob-3 f 3--- (/ce,/e 7
FAX CELL EMAIL C_-I F,.c., Po ,,,<<,
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN I REVIEW NOTES
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