Loading...
HomeMy WebLinkAboutBLDG-25-616 MASSACH SETTS UNIFORM APPLICATION FORA ERMIT TO PERFORM GAS FITTING WORK O V ,T I� / L ✓ Z.. PERMIT# �, er- -` hhA DATE ` ' 6/6 �� ..,� CITY " ., `'j JOBSITE ADDRESS ( OWNERS NAME GOWNER ADDRESS 6 ' I TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL cg---J PR NT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 . 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER, _ -, ��� ; COOK STOVE DIRECT VENT HEATER 1 7 DRYER - Nn - O 2U2b 1 FIREPLACE i FRYOLATOR FURNACE I •• GENERATOR ; _ d GRILLE { INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER • ROOM 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 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA . CHECKING THE 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 ` Massachusetts General Laws,and that my signature on this permit application waives this 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 accur 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 I P rtinent provision of the �` Massachusetts State Plumbing Co nd Chapter 142 of the General Laws. `1 PLUMBER-GASFITTER ME t7'11 `M V-Tc' /14405 'LL//' SIGNATURE MP . - GF JGF DGI❑ CORPORATI \1❑# PA.RTNERSHIP # L C El# G I J (� ADDRESS 2 �' /V Tr�` O `� v�'�— COMPANY IaA - /�� CITY Yr ' / . STATE W4ZIP © TE��cr 560 5*.5 FAX CELL EMAIL 1 Q /4'L4 ►v ov cJ5 7i ,•co, C k9`- • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES • Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT f PLAN REVIEW NOTES • •