HomeMy WebLinkAboutBLDG-26-339 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�— MA DATEI 5/J4 AL I PERMIT# 5-b -Z -339
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JOBSITE ADDRESS z J i,i /C',.J _OWNER'S NAME I Flynn Ga.
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G OWNER ADDRESS i„2q E44}} Ln B I]P L M4 , 1TELrQ7F 3S7 kll7 IF' I I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:,__. RENOVATION: '" REPLACEMENT:❑ PLANS SUBMITTED:YES El NO
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER -...-
BOOSTER
CONVERSION BURNER
COOK STOVE Q
DIRECT VENT HEATER .
DRYER
FIREPLACE .
FRYOLATOR
FURNACE
GENERATOR ,
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/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 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does lot 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'r AGENT❑
SIGNATURE OF OW R OR AGENT
I h eby 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 ith all P rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME hPiviv, (Y)c-e^Cie, LICENSE#it ba 4. SIGNATURE
MP V MGF JP JGF❑LPG( CORPORATION # PARTNERSHIP❑#I LLC ]#
COMPANY NAME: ADDRESS R E C E I• -E D
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CITY j _ STATE ZIP TEL I
FAX CELL EMAIL ,FAX 14 2028 I
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES