HomeMy WebLinkAboutBLDG-20-006291 : :� MASSACHUSETTS UNIFORM APPLICATION FOR A P MET TO PERFORM GAS FITTING WORK
4.7 g
` 1�6' CITY ' / oZa # / bao-004, t`_._, -- M l� r/ h4�, DATE 'S PERMIT �
JOBSITE ADDRESS 7 L)4-C to S 4'ti-e'iOWNERS NAME \J O e J / 4
GOWNER ADDRESS if C, ) 1e' i '(7 EL T. ?— f CFAX
TYPE OR UUrPsiO GO/\ 'L :2%
PRINT OCCUPANCY TYPE COMMERCIAL E EDJCATIONAL ❑ RESIDENTIAL( (G
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—I BSM 1 2 3 1 5 6 7 8 9 10 111 12 '13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER i
. I
DRYER
i
FIREPLACE
FRYOLATOR p
FURNACE
GENERATOR a v T 5/0(9 /
GRILLE i
INFRARED HEATER --~ I
LABORATORY COCKS • i
MAKEUP AIR UNIT
OVEN i
POOL HEATER • 1
ROOM/SPACE HEATER I
ROOF TOP UNIT
TEST ...
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
OTHER
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 POLICY E 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 this requirement.
I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT j
•ili 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 all Pertinent provision of the I
Massachusetts State Plumbing Code and C apter 142 of the General Laws...
Li
PLUMBER-GASFITTER NAME F r r
N a C,C. LICENSE#f g cp� SIGR-gl 1 .‘"-----j
MP ❑ MGF❑ JP [ JGF❑ LPG' /
' CORPORATION❑# PARTNERSHIP/ ❑#� LLC❑l#!/y I
COMPANY NAME 1�'t--'r P SS9' re 6 c /O l v�Y "` I ADD ,E�� S /
CITY W NGt I M a O1-ti STATE 1/(All— ZIP 0 ?L 73 TEL )7 y Ti d r/e Z
FAX CELL EMAIL 5 n,-ems ." mac,--r 49.5 A t t L- to,
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY _INAL INSPEC
TION�NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT ft
PLAN REVIEW NOTES