HomeMy WebLinkAboutBLDG-24-118 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CIT1 • \---c MA DATE 2-I1(nt ZL{ PERMIT# 1140G-11- i 14
JOBSITE ADDRESS \ - OU (--` L1i \ OWNERS NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL YRU T ❑ DU ATIGIJ.4L ❑ RESIDENTIAL
CLEARLY NEW:0 RENOVATION:L7 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOORS-. BEM 1 2 3 1 5 6 7 a 9 10 11 12 13 BOILER 11
BOOSTER
CONVERSION BBURNERS
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER _
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER ,�'•' � `.^ • . .
ROOM!SPACE HEATER
ROOF TOP UNIT 1 TEST FEB 6 2T)Zli '
UNIT HEATER Y
UNVENTED ROOM HEATER I
WATER HEATER I
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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 tins 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
ti and that all plumbing work and Installations performed under the permit Issued for this application a in comp' a eminent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBS .ASFITTER NAME LICENSE#kT1t I SIGNATURE
MP MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑tl PARTNERSHIP❑ft LLC
COMPANY NAME
,T`L(NrS �LIANA -j/Qe, I NYC, ADDRESS - TK•- E CC�LI,NY li' P Y
CITY t) L>:Uf)U t`1 STATE AN A" ZIP U (00 TEL FAX CELL-V-4 G.JGbv Nk'.S
CC'S EMAIL TIAPLu Ng,®V f�
M [v
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