The URL can be used to link to this page

38B-028 (3) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY � f? f��u, Cil ! MA DA''T11EIO(a-Ob-LSo1PERMIT#�� f'"'i+ JOBSITEADpRESS�'1$ry- \�11 OVc �`FI OWNER'SNAME f (' \.] OWNER ADDRESS _ TEl�yt3 r7.(OFAXE TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL[ RESIOENTIAAS(— PRINT CLEARLY NEW El RENOVATION:(,--] REPLACEMENT: PLANS SUBMITTED: YESEI NQ� APPLIANCESZ FLOORS- BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BOILER - - BOOSTER �' CO VERSION BURNER _ - O COOKSTOVE - r DIRECT VENT HEATER -- - - DRYER FIREPLACE FURNACE IV I GENERATOR - _ - GRILLE DH ER _ I LABORATORYCOCKS MAKEUP AIR UNIT - - - OVEN POOL HEATER ROOM SPACE HEATER - ROOF TOP UNIT - - -- TEST UNIT HEATER - UNVENTED ROOM HEATER - - WATER HEAT THER GAS PIPING _ - - - — - - 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 0 OTHER TYPE INDEMNITY El BOND ` OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mayachuseus;General Laws,and that my signature on this permit application waives this requirement. c CHECK ONE ONLY: OWNER E3 AGENTS SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and inf.r,,m n I have submitted or entered regarding this application are t nd accurate to the best of m knowledge and that an plumbing work and installations recorded under the permit issued for this application will be In w rem mth e0 Pertinent is of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASF17ER NAME Francis A.Corkery LICENSE# 3745 SIG ATUR MPQ MGFd JPEJ JGFQ LPGIQ CORPORATION � ..--- LLC❑#� COMPANY NAMEJ Columbia Gas of MassachusettsADDRESS 2025 Roosevelt Avenue CITY S rin fieid t --T STATE�ZIP 01101 _ _TEL 508-b8C-0100 ext 1324 FAx CELLI _ IEM41L --.1 ROUGH GAS MSPECTIONfNQnS THISPAGRFORIN,PECTORUSEONLY FINAL INSPECTION NOTES Yn No THR�A{PP�LICATION SERM M THE PERMR ❑ ❑ PEW# PLAN REVIEW NOTES c jl MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING FITTTING W A CITY �pr � I MA DATE PERMIT# JOBSITEADDRESS _Ck\ _. _ WNER'S NAME G i nm4.. n1 OWNERADDRESS TE FAX FAX TYPEOR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEWT RENOVATION:17 REPLACEMENT:© PLANS SUBMITTED: YESO NDe APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 B 9 10 1 11 12 13 14 BOILER _ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER !' _ DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT - - - OVEN POOL HEATER -- - — - - ROOM/SPACE HEAT ER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER _ { WATER HEATER OTHER GAS PIPING INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO 17 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY® BOND L-1 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 73 AGENT ❑ I hereby derail that all of the details and information I have submitted or entered regarding this application are t ntl accurate to the best of my knowledge and that all plumbing wor8 and installations performed under the permit issued for this application will be in m nce with all Pertinent is of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t PLUMBER-GASFITTER NAME Francis A.Corkery _ LICENSE#F3745 SIGNATURE MPEI MGF❑ JP® JGFO LPGIQ CORPORATIONO# PARTNERSHIPF7 LLC Q#�� COMPANY NAME. Columbia Gas of Massachusetts ADDRESS 2025 Roosevelt Avenue _ CITY I S rngfieldSTATEF MA ZIP 01101 _ TEL 508-580-0100 ext.1324 FAX DELEMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Tn No >r.$f✓/Le THIS APPLICATION 5ERYE5 A5 THE PERMR ❑ ❑ FEE: { PERMRM PLAN REVIEW NOTES ■ Complete Items 1,2,and 3. a 5i nature ■ Print your name and address on the reve!e4 X �� -�"'" O Asap so that we can return the card to You. ■ Attach this card to the back of the mailpiece, He°e1v,cl b nuaj 9. D of aihv or on the froat H space permits ,(/, t. Mica MrMmsed b: D.Ied.frowyptldreesdlRereplromlteml? ❑Yes �1 f�f Q�✓t � Y2/6/c141'(_ If YES,enter delivery address below: O No '-✓8 S C7-1i <eriie%!Rd f,f)rtltclMSbctr�� X/k p/CY!!o lillllllllllllllllllllllllll1111111Illlllllll s r" l ❑ due$ DI'M reb6 . ❑Mutl$19mm flecbklel GNhrery ❑PepINaW M011nsMEtg.1 9590940222046193896327 � edtiaaarctm oaxrplrn ¢genan FlecatNrm ❑COlkbton odlVgy p9plug15a 2. Ai:icle Number(�ianskr lmm swvlcelabeQ ��iecl on D&iwrY nmbbteel oeuvery osignatureconhmeuan^� 7016 6910 0001 6815 6166 PS Form 381'1,July 2015 PSN 7530-02W0-9853 Domestic ftetum Receipt ; U.S. Postal Service'" CERTIFIED • o RECEIPT � a al Mail� f a s D" io<afRosras ee B Fees" O g —.1 �0 WtNt4m o'/L(rXda+�. e r6'a6E9'A.94'EI