HomeMy WebLinkAboutBLDG-24-619 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'lif_
CITY kliFt�rAOL MA DATE Jr) Ill 24- PE IT#ILA6-Zh- &I9
JOBSITE ADDRESS 6,e ---- DINNER'S NAME2-sti.a1 L.L-E-..
GOWNER ADDRESS 5/L 1v1� TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 4:1,./...---_
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:Nk PLANS SUBMITTED:YES❑ NO 0
APPLIANCES 1 FLOORS BSM 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 91YL
INFRARED HEATER
LABORATORY COCKS ___I
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM 1 SPACE HEATER
ROOF TOP UNIT - F¢ - I -
TEST
UNIT HEATER -
UNVENTED
WATER HEATERROOM HEATER I ' r
iri
OTHER / [, a w,,u6 PAR MENTT
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 COVERAGE KING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
OWNERS 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❑
J 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 acc rate 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 all Pertinent provision of the
, • Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASF TTER NAME ik -r --W LICENSE# /5�9/l SIGNATURE
MP AGF JP JGF PGI❑ CORPORATION
S❑# PARTNERSHIP❑# LLC❑#
COMPANY NAM,j 13, .....k) O/./0, .ft&JT®r JLe3 DRESS
CITY '7�0 V 1e STATE NI rfZIP II . TE 41kf' .‘ 'V 3
FAX CELL EMAI A / 01/ i / 0 OS
qw4c
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE QN1Y FINAL INSPECIiPN jQTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT I I I 1
•
FEE: $ PERMIT #
PLAN REVIEW NOTES