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HomeMy WebLinkAboutG-19-2806 • �'n�"�� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK itp�i=-'-re'` ,"p e; CITY YO1/4 IMbIAL MA DATE Ilibi6 PERMIT#IiLO6 (V4 JOBSITE ADDRESS b [4W LoAt1 OWNER'S NAME Ed _Mt- U.O Geory! Cy t G ' OWNER ADDRESS SAA - TELCI7 405-0C 37 FAX TYPEOR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL RINT CLEARLY NEW:0 RENOVATION:® REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 FLOORS-. BSM 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT — RE C E I V ED OVEN POOL HEATER • ROOM I SPACE HEATER NOV 6 al) ROOF TOP UNIT TEST . . _. r�urrytiutPNn rnr UNIT HEATER — UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE ,�/ I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES LyNO 0 J I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 2 LIABILITY INSURANCE POLICY 12OTHER TYPE INDEMNITY ❑ BOND 0 1 Nl 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 0 AGENT 0 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 toper- -wi Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 11) PLUMBER-GASFITTER NAME LICENSE if la. in ':GNATURE • MP[rMGF 0 JP ❑ JGF❑ LPGI❑r CORPORATION]ft PARTNERSHIP 0# LLC s a�# COMPANY NAME LO P Z P(w.,VIS+( '4- 4(4. 9 ADDRESS 141I `g1l.'� ST CITY CruST 4g t` �`�'� 0 STATE 14 Q ZIP 0)-333 (, TEL FAX CELLav7"oE0y EMAIL taco 9.0 � � ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES A$THE PERMIT 0 0 9y/ FEE: $ PERMIT PLAN REVIEW NOTES �/L / CL • . . . . S , ©s . ', ' « qa o 0 F. \ \; 7 -off w zz= {- ■ .. q gx ƒfs ; m F� & e '.4 T. n. 4 s� = rte� , {oo ® 7am � o � e c , xr cr* — zz Its , r mE o ■ � � ` iK� Z0 C,-I ` � R Co) -I to m <%Xrn � a � j »& m 1).,>,..1 z$ $ aa -n - ¥ Fi \ : «� , in �o+ r o � f : sow mo � k\ /f �o o § ; § oz,§� . \� k2 \;k�E zto§q ®km ƒ#`z> /73 2..%:1 ° » { 77 ƒ] r% e y . . » - > »73c r r . : m2 e : n2 : » 0,4 q . 49q \ « . ƒ . \ . - %� . y . cn : 171 i / \\ , §. . £ x J)� ( § y mm . , w «» ! &_«+ \ _ y 70-50 r/2. ,,16 Mc • _ Tb 14144A )rktiv, l'aat¢rv, 7 ettuN ltM0 yr fenvticr GOd)K i /s � /✓oma La t it2/41 yotemo4, 97444k-- Yov 1671X 446. - i RECEIVED NOV - NOV 06 2018 BUILDING DEPARTMENT By