HomeMy WebLinkAboutBLDG-23-9691 3 • i
`. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 4. r1r MA DATE i 1,
.0 23 PERMIT# a�G-Z-3-`4-"/
JOBSITE ADDRESS 5 5 t1 13rvY/' lY OWNER'S NAME Gil i i33i jc i'4 ZaV?
OWNER ADDRESS TEL Tt / 726 ree Z,_,FAX
TYPE OR OCCUPANCY TYPE COMMER L❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 s 9 10 11 12 13 1T
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
OR
FURNACE \t/C-
GENERATOR
GRILLE
INFRARED HEATER 1 `,; 't I
LABORATORY COCKS
MAKEUP AIR UNIT tieV 2 J ma
OVEN
POOL HEATER • 1
ROOM I SPACE HEATER s L j LP_ ry`? F. L N
ROOF TOP UNIT _ _. = i
TEST •._._ -- -.
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equival which meets the requirements of MGL.Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE .BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
1` 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
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Lo
PLUMBER-GASFITTER NAME LICENSE# g SIGNATURE
MP 0 MGF❑ JP JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME' 'I G- 1' 5 U4/`1 13,(-J ADDRESS Sq . ,,,-1--D c�
CITY Ui-oc,i4� 5 fir't/ i... STATE Al i4 ZIP(>l (/?(: TEL 7f3 5 l 341
FAX CELL EMAIL' '1 LW/.5 l .v1M/3I4 l j�--t3-l(a.'
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION{NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
•