HomeMy WebLinkAboutBLDG-18-002056 (“Pr g, 0f� Mkt/nil-0051C
�;��— MASSACH SETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.. CITY �r+�Yma'h�1n MA DATE �O I $ ( I� PERMIT Lk-06- /8'-caaos .
JOBSITEADDRESS 6 Un>ntcrcA OWNER'S NAME Ermn 0- /3CIl7kr
GOWNER ADDRESS & .r. TEL '7711 268- RO FAX ,
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL V.
PRINT
CLEARLY NEW:DE RENOVATION: 0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
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APPLIANCES 7 FLOORS- BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE / -
DIRECT VENT HEATER -
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR _ •
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GRILLE R E C 'i U!: C u
' INFRARED HEATER —
LABORATORY COCKS
r -
MAKEUP AIR UNIT -OCT OJ -017 -
OVEN _
POOL HEATER - Li UT; s L,, a t�- ii
ROOM I SPACE HEATER (tby
ROOF TOP UNIT toU'c_ t L
TEST . G o$ fit-e. • . . . . . .. ...,_ .. . . ........ .. -
UNIT HEATER QlvE. b� _
LINVENTED ROOM HEATER
WATER HEATER .
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES�] NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ,i OTHER TYPE INDEMNITY 0 BOND 0
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 0
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 accurate to the best of my knowled.e
'3- and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with - . vis'.--.f the
Massachusetts State Plumbing Code and Chapter 142 of the General iaws.
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PLUMBER-GASFITTER NAME Ahdnv' S, C-C-Pe N LICENSE# /.x833 SIG"Tr
MP p3I MGF❑ JP 0 JGF❑/ LPG!❑ CORPORATION®C365 PARTNERSHIP 0# LLC 0#
COMPANY MAME AS.H- lh,ct10111,Ii01I :5:14 C, ADDRESS 3OG R/v.b,/fiej' Oft br
CITY PreWS-ft✓ STATE mfr) ZIP 02.61I / '. ' TEL SO€ .37 76/77
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FAX CELL SDIl/ ' EMAIL la5Vt pifchgyr3 le 110itI;,t/;CAWI
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No •
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I n A 71 THIS APPLICATION SERVES AS THE PERMIT 0 0
)40 /Q/ /7j7 FEE: $ PERMIT fi
ELAN REVIEW NOTES
One
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