HomeMy WebLinkAboutG-14-670 • ,. p16 r9-
gLk MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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=SLI CITYI jer/]/j1UVplk, a MA DATE, I L. j3 PERMIT# M'- 6771'. .r
JOBSIfE
ADDRESS!aL- 1,41._. T7WenO. l OWNER'S NAME! AL(t. 1
GOWNER ADDRESS 6rer TEL'!fQ J-$2-11-7e6 JFAX ;
TYPE OR
PST OCCUPANCY TYPE COMMERCIALS EDUCATIONAL® RESIDENTIAL
CLEARLY NEW RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NOS
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APPLIANCES-1 FLOORS-. BSM 1 2 3 4 5 6 7 • 8 9 10 11 12 13 14
V BOILER - - - M — 'M ' ,�m
BOOSTER MM _ M __ M .
CONVERSION BURNER
DIRECT VENT HEATER � nialla ”
DRYER SrISIMI�W AIM
FIREPLACE > _►T _,_TSaI __S
FURNACE MAINIMINSPWRIalainTriliailltill. 'an'
GENERATOR 'al
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LWISIDIPSIMSOT
GRILLE
INFR
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NS
POOL HEATER ' INIIIMOSSIPAPOS
ROOM I SPACE HEATER M _ a
ROOF TOP UNIT • ' 1.1fM ..
TEST — a
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WM I . Wi�
UNVENTED ROOM HEATER UNIT HEATER ISM, /
OTHER ' °��✓ /7 .� .ill ...
WATER EATER �_ :-. _9 _- .. _'� S l .
INSURANCE COVERAGE r
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL, h.142 YES NO U
culc:xI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE' GE BY CHECKING THE APPROPRIATE BOX BELOW E1y�GKAO _
LIABILITY INSURANCE POLICY1IL OTHER TYPE INDEMNITY 0 BOND 0 P60
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 ccurate to/oyyy•st of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in co n h all Pepro/=ion of the
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Massachusetts State Plumbing Code an hapter 142 of the eneral Laws.
PLUMBER-GASFITTER NAME /,„/)140t. tr2v/ I LICENSE# • GNATURE
MP d ®MGF 0 JP JGF LPG'D' CORPORATION#C1.PARTNERSHIP D# 1 LLC 0#1---1COMPAN``AANANNYY NAME: /4,1/al Mr 411,.. r ADDRESS 134 /,.
' CITY '5/ pei./ut t7 • 1 STATE JZIPW71 "A TELL uJ-3& '/ i
FAX�y , ELLI EMAIL 1
77 ((a
•
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
I /2Of/ Ofd Yes No
1 7/iy THIS APPLICATION SERVES AS THE PERMIT 0 0 � j [/�1 p�/j�
FEE: $ PERMIT# Sir`i " " n '� / 10A
PLAN REVIEW NOTES /�/4-
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