Loading...
HomeMy WebLinkAboutBLDG-16-004345 172 A? P PA Rees_ l (22 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK aL— CITY l Town of�aaaic}Cpt.�p t-1 1 MA DATE I J—22—/k, 1 PERMIT# I�f' —16-00` y94' • f JOBSITEADDRESS! 2 A. LI l-, 'MAtr�7 IOWNER'SNAME ! ' to-A,g._ Iyala _ 1 N......5 OWNER ADDRESS TELj IFAX( TYPE OR . OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL RESIDENTIALD PRINT CLEARLY NEW:D RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO Li APPLIANCES 1 FLOORS ESM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ... -•77.2____-•____.,73I t 3i #i L, __J _ii.__ BOOSTER Iii � fiI 3' r —q —r CONVERSION BURNER DRYER �l}`. i COOK STOVE WallaninDIRECT VENT HEATER � M;h l li — 1I jI FIREPLACE - l___ _I.._.-1 _�T,.�i FRYOLATOR ' EI yL tf __ i yi - FURNACE _ GENERATOR _.�..'IL,, _s ��1i .!_...I._ll 11_1 GRILLE ,it' ! I I ,i il II [ii ' INFRARED HEATER h __ 7-7-67-11; I is g 'i! ii i LABORATORY COCKS , .; _-,- Marin.t..r : jr -r_ ` #I_.,_,_- MAKEUP AIR UNIT I + ." II f 11. If I _ .. � a� OVEN _ „.___;',_,__,I EI '1J I POOL HEATER ' '___It___ "I ' . 4'.4:" ` I N$QEQ • , ! 11 ,5 ROOM I SPACE HEATER ; (' It I—II 1 _T„r ROOF TOP UNIT • l� ,m F i I Id ilia ". ) 1 TEST __ ► I ,,. iCr gcL. .1111 r .i .-- • r • UNIT HEATER _ ' . ,I-_ UNVENTED ROOM HEATER 1 _ - i� 3 ; ' -_ X44_4, WATER . - I .rI _ I.__ ,. .t� _ ._I 11 _ OTHER1 EATER n _!R i! 4i —11 J • INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES W1\10 4IF_YDU CHECKED-YES,PLEASE INDICATETHESYPE_OF_CDVERAGE BY CHECKING-THE APPROPRIATE BOX BELOW. —. ' LABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY © 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 i AGENT Ei 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 Pertjpent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r//`� /Z • PLUMBER-GASFITTER NAME ells LICENSE# J Q 'IAA,.)- SIGNATURE1 MP lai�MGF D JP 0 JGF D LPGI® CORPORATION 0#=MI PARTNERSHIP D# 1 LLC Di I COMPANY NAME) E MAT,M ice^ OS ADDRESS &To OLD Q I —9-0. ICITY (�t�Ini STATE? mitIZIP a —_ a TEL H-10(^7-9o9--i�'2 1 • FAXI CELL IEMAIL I aCi • ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES f 1 _ • • Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • • • • • `.