HomeMy WebLinkAboutBLDG-18-006927 •
1::::.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
milli-F. CITY fy*`!� ati MA DATE f"� r( ERMIT#f/WG-�-42tf 7
JOBSITE ADDRESS' Z�ri rt00 L{• (OWNER'S NAME G n i 10 a r'r o 57
GOWNER ADDRESS I --- ----;t_Trial7ig-C9 2.7 IFAX' I
TYPE OR OCCUPANCY TYPE COMMERCIAL;,.] EDUCATIONAL ,} RESIDENTIAL
PRINT
CLEARLY NEW:,,,,.. RENOVATION:A REPLACEMENT:_I PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _J-1'I-I J J_ILL.!1-I_I I'111
BOOSTER _I J-_1._I Tf_(_LD'LLI_J_J_1 C_ I—1
CONVERSION BURNER -J � I ri_i__J t-J_J _) _J p_j, " 1_I
COOK STOVE LLI 1_ __J I- t.J.Li iLLImo' I_ILi]I_Li_J .
DIRECT VENT HEATER '11-1_x;11 LJ J 11�I 1.1:1_1, __I_J
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GENERATOR
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GRILLE _I-J 1-.J__LI-I_I-J'_J-J I-I-U -J_J
INFRARED HEATER . _J_f-J _J_i__Til,_J 1 1 j11_J'_J--I _J
LABORATORY COCKS ._I 2:111_111 I__1 " -Li 1 - I t-_J:-i_Li--j_1
it MAKEUP AIR UNIT f_J'_I -J_--f _I I _I ' _I _-I-.J
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POOL HEATER _ I - f____J _J 1___.1 I__I-tit CpI. I . _•_.J_J
ROOM I SPACE HEATER _l_I_�J _I _I __J I ' ""1-`'T'--t•---I _-1 _I
ROOF TOP UNIT ___I-1-_-.-J-J_t_t 11 ' l I,._J I "_J LU
TEST _I_J-J_I-J_I • ___ I •��iIL4 I_I 1
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UNVENTED ROOM HEATER • �J_'_I J_I i_ift�� vI DEP4RTAnd T LI-J
WATER HEATER. ----------_.._ 1.4ITILI-JLU_f-- -}--Jr--}_L- I-1-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 I®NO '
C I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW C, Ica/ tll1310
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LIABILITY INSURANCE POUCY VI OTHER TYPE INDEMNITY 'J BOND D
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 l AGENT :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 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 General Laws. ,, rt
PLUMBER-GASFITTER NAME; 1V..Q S I LICENSE#tI j�� f SIGNATURE ,
•MPD MGF JP JGF D LPGI CORPORATION.:3#1-131.56P• r PARTNERSHIP:..-1# -1 LLC:J#i^. _ t
COMPANY NAME' 03 r`L ap ADDRESS
CITY n , ;#1. �1 . - I STATEITEL
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FAX' I CELL' IEMAIL! S r er • M($ C tie �5 ,n�'Q-ff ` co,-}-, I
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
/ Yes No
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M` �/ , /� Tb or- THIS APPLICATION SERVES AS THE PERMIT 0 0
th/9J/�,'f FEE: $ 4 PERMIT#
FLAN REVIEW NOTES rl
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