HomeMy WebLinkAboutG-18-6001 l'a .. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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_11_ : CITY ' *Arra) --�, MA DATE ��o iPERMIT# /° -0I /t- ' Z(
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JOBSIT ADDRESS t lO �zesc�.b,.,z,...o-- c.:y-eri OWNER'S NAME :C a - (
GOWNER ADDRESS r� �,,,r_ `h T�e4 yea j C• - -2 . . FAX
RTYPIINOT OCCUPANCY TYPE COMIyIERCIAL;LI EDUCATIONAL J RESIDENTIAL:4
CLEARLY NEW:,. RENOVATION: REPLACEMENT:,_I PLANS SUBMITTED: YES j NOD
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _I_JJ_JI_J—J_1—JI__I_ I—J'—JI
BOOSTER _I_J-1_I I L1—]'_J—11_J J—] I—]
CONVERSION BURNER • —1-J__I 111._I,I ___1.______I__LI 1'_J,_J__I
COOK STOVE _1-t__1_I_J UI 1-1_J •_JI_' 1—J_1 I .
DIRECT VENT HEATER __-J - }_I__;—I__I_1_J LL—ILLI _Li I_j:U._J
DRYER• _J1_J_j_j:Li I I _1I—J 11 —JI
FIREPLACE
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JFRYOLATOR `_1- —1'_—J—f—J—I —J--I—i_—1—J—J —J—J
FURNACE 1 'IL)? !_—I"_ -J_-___Ii _J—J I-_i__J--
GENERATOR
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GRILLE 1 ""1 _ .I 1 t_--I_1_1-.. .1_J_l_—I—_J _1_J..__..INFRARED HEATER . _ -I:lit t"=1_J I__I ... I__I_� =J LULL(_.I t
LABORATORY COCKS _l_]_-_J'____;_J I—J 1__J—_J—J—J—J I—J
MAKEUP AIR UNIT _r_IL_J_1 __i I_p__JJ I_1_i ___J
t OVEN __1—! 1 _i—__!'_—J__J__i —J_1'_J-J-__I_____I_._f
POOL HEATER 1 i 1 • i__J _
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ROOM/SPACE HEATER - - I _ - I _ -I . I i_II_i 1 I _i
ROOF TOP UNIT —__I_J I—J_t__I__J—J Vi i(__I I—J_J 1
TEST _I J I_r—J, 1—_J__J_i_I I_I_t_1_{
UNIT HEATER __I_J_J_U`I.1:_i_I_J I 1"1 1_Li_I I
UNVENTED ROOM HEATER • 1_J_LJ i__i_J___J_J__Li_11—J _1 —J
WATER HEA,TER. -______ _____ _J1_i_I1_II_J_J___I_i _I____J—J_)
OTHERRi...„,..__.._._......._--- _I—i—I_I —J—_r ice!_J__J—l—J-1—i_J
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INSURANCE COVERAGE
C I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES IJ NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE INDEMNITY ;,1 BOND D
OWNER'S INSURANCE 0 r -• am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Gene .. th. y signature on this permit application waives this requirement.
Or
CHECK ONE ONLY: OWNER ,AGENT Li
SIGNA r.' •• OWNER OR AGENT
1 hereby certify that a8 • •- •etails and Information I have submitted or entered regarding this application are tnr and accurate to the best of my knowledge
and that all plum•' •work and Installations performed under the permit Issued for this application will be In comp with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (r��n
PLUMBER GASFITTER NAME i_...�I—. •4_...____._._.__._.—..._.-.r
�+15a �CCn t LICENSE# .S5- SIGNATURE
MP13 MGF J JP;y} JGFJ 1201 CI, CORPORATION CJ#r - 1PARTNERSHIP'.,1# --- LLC:IC
COMPANY NAME: A1C v f Cf rim I ADDRESS 2& ' (}'Jain (. d•+
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dal. I STATE/rti , IP: 1 (TEL• sciN,C.- Fo-1/96L«-(
FAX (CELL' • !EMAIL! /_tiSC9'AC61� -. as&0.Can FZ #..4__._�,
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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 El 0
FEE $ PERMITg `/'� v' '
RLAN REVIEW NOTES 0,C
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