HomeMy WebLinkAboutBLDG-25-639 MASSACHUSETTS UNIFORM APPLICATION FOR ERMFT TO PERFORM GAS FITTING WORK
CITY (J // _
IM,, DATE t//A �� 7"7-- �PEERMIIITT# -ZS-637
JGBSITE ADDRESS 3 13 1( 4n Pi tan I�YA(d"-L t C E "
OWNER ADDRESS `-}"{�{'� TEL LL
TYPE OR F --�_
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL❑
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑
PLANS SUBMITTED:YES❑ NO❑
APPLIANCES 7 FLOORS-r BEM 1 2 3 4 5 6
BOILER 7 8 9 [ 10 11 12 13 14
BOOSTER
CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER
DRYER _
FIREPLACE
FRYOLATOR '—�
FURNACE
GENERATOR. •
GRILLE
INFRARED HEATER _ i _ i
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN -
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST I,Ir r' ; .3 1u2j
UNIT HEATER I
UNVENTED ROOM HEATER
WATER HEATER -
OTHER I /9 11— .1
INSURANCE COVERAGE -
I have a current liability insurance policy or its substantial equivale ich meets the requirements of MGL Ch.142 YES ND❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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.
CHECK ONE ONLY: OWNER 0 AGENT El
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
and that all plumbing work and installations performed under the permit issued for this application wit be In compliance wltl]�at Pertinent provision of the
Li) Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / /^/
PLUMBER-GASFITTER AMEN
LICENSE# SIGNATURE
MP dGF P JGF 0 LPGI❑ CORPORATION/ 0# PARTNERSHIP 0# LLc 0#
COMPANY NAME P`f ADDRESS �� 1 �J' �J /�->
CITY f l 712-!/Vl/,U [ N STATE ZIP TEL Jl�)[nl `J�^O b
FAX CELL EMAIL (05
-11 70.a) C( /('''y`I
)EtOUG GAS INSPECTION Ift3TES •
AIM PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERiti31T• ❑ ❑
FEE: PERMIT##
Ps AN iZEVIEW NOTES