HomeMy WebLinkAboutBLDG-20-003969 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY Yli204OC-7 Cc
MA DATE I.-. .CJ� 20 PERMIT#� 'oI/e?
JOBSTE ADDRESS / /7 / /- 3c 4 L ,' c-- OWNER'S NAME tJJ Y#'(G �
OWNER ADDRESS TE1ji
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑
APPLIANCES FLOORS-+ SSId 1 2 3 4 5 6 7 8 9 10 11 12 13 1e
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 ,Al 1
ROOIuf I SPACE HEATER
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 MGL Ch.142 YES 11 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW
LUABIUTY INSURANCE POLICY [ OTHER TYPE IIdDEMNITY❑ 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 0 AG 0
SIGNATURE OF OWNER OR AGENT
sts I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and urate to the best of knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian th at Perti p n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER-GASFITTER NAME LICENSE#3%5 ? SIGNATU
MP❑ MGF 0 JP❑ JGF LI LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME,\-.141-I1 i -A(L ADDRESS 2 F.413Y41•ILi !mil •
CITY Plhat T I , STATE r4,'n Vt,- ZIP c7 -360 TEL rO5-1Y 4s-4��,55
FAX CELL EMAIL iWetNI� '4r,+C otzsCZ`&
Leg- col-5907_ I ��
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT l
FEE: $ PERMIT ft
PLAN REVIEW NOTES_