HomeMy WebLinkAboutBLDG-26-534 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T PERFORM GAS FITTING WORK
CITY ��Lr�'rNL d ri� /
/+ MA DATE PERMIT?f-t�JIUXt'ui ��3i./
JOBSITE,ADDRESS yZ_5(./ F UC_ OWNERS N.AME`J p✓//1 / 672 ex-
OWNER ADDRESS 7 TEL 7 l Z-/Y/ FAXTY
PPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[ '
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:a PLANS SUBMITTED:YES 0 NO X
APPLIANCES Z 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 -1
DRYER -
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT -
OVEN
POOL HEATER -
ROOMISPACE HEATER -
ROOF TOP UNIT
TEST .. I
_
UNIT HEATER
INVENTED 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 [ENO❑
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 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❑
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 will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the Gener I Laws. c /�/ n �`
NAME/1/ C� MC13 (1 EN
PLUMBER-r,ASFITTER NAME I LICENSE tt SIGNATURE
MP❑ MGF❑ JP JGF❑ LPGI❑� CORPORATION❑#/01dK PARTNERSHIP 0# LLC❑#
COMPANY NAME rM i Y 4 ADDRESS -3 7 /G n 6./-2 G};t-
CITY C/ /I ,//J STATE[/4 ZIP Q Z Cu O/ TEL )7y 7/6 ,/Z?
FAX CELL EMAIL S 5cr•M c J r i a(GGO_aq!k,t4 (•( 4f
C vl-rz C a 7 (0 0 1uf a\ J
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑•
❑
FEE: $ PERMIT It
PLAN REVIEW NOTES
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