HomeMy WebLinkAboutG-11-868 Pee 1— s 6 - 2a -- 11
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING
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C,-4.0'17.0'= ^ CfTYITOWN: S VAMInorir4 .J STATE:A. APPLICATION DATE: 6P - 2.,,6 -id
JOB ADDRESS: 2S 4>'
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GOCCUPANCY TYPE: COMMERCIALE RESIDENTIAL PLANS SUBMITTED: YES NOp'
NEW': ALTERATION✓ REPLACEMENT❑ REMOVAUDEMOLITION❑
r NATURAL& LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT-APPLIANCES-SYSTEMS 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS
AIR ROTATION UNIT r---I FURNACE: ALL TYPESTEMP HEATING EQUIPMENT
BOILER:ALL TYPES _1 GAS PIPING THERMAL OXIDIZER
BOOSTER --1 GENERATOR(STATIONARY ENGINE) fl TURBINE
v,,\. BROILER ----I ILLUMINATING APPLIANCE I UNIT HEATER
N i BURNER: ALL TYPES INCINERATOR I WATER HEATER: ALL TYPES
liti COGENERATION UNIT ----1, INDUSTRIAL AIR HANDLER EQUIPMENT OVER 12,500MBH
4 4.1 COFFEE ROASTER ; INFRARED HEATER am OTHER NOT LISTED1
'I COOK APPLIANCE HOUSEHOLD ----1 KILN I GLORY HOLE I CRUCIBLE ;_
o�p COOK APPLIANCE COMMERCIAL LABORATORY COCKSR E E I V t
DECORATIVE APPLIANCE
--
DECORATIVE AIR UNIT ----!
DIRECT VENT APPLIANCE --J MECHANICAL EXHAUST EQUIPMENT
DRYER: ALL TYPES —1 OVEN: ALL TYPESJUN 3 20]!
FIREPLACE:VENTED!UN VENTED f POOL HEATER
FRYOLATOR I ROOF TOP UNIT BUILDING DEPT.
FUEL CELL I ROOM HEATER-VENTEDIVENTLESS
PLUMBING I GAS FITTING FIRM INFORMATION fCCHH�E,C�K�ONE ONLY
NAME:DEC-wa'.Y$de/1GAdlD1rf�,,ADDRESS: P douldoni ..,e_f ❑Corporation Business I
CITY: �i45 �' MA D 9�� Partnership Business I
( - STATE: ZIP: .- .....I.......,------j LLC Business I
TEL:ISag' tin tM4AX: I EMAIL:/ — q � 'Gincorporated
NAME OF LICENSED PLUMBER I GAS FITTER: Sr2r /Y4o t_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES® NO❑
If you have checked Al please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy a Other type of indemnity❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havt the insurance coverage required by Chapter 142 of the Massachusetts General
Laws,and that my signature on this permit application wlbes this requirement.
CHECK ONE ONLY
OWNER❑ AGENT 0
Signature of Owner
�orTOwner's Agent
OWNER'S NAME: ! ry pu' S 2 1 TEL: 1 FAX r I
I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application Is true and accurate to
the best of my knowledge.I certify that all plumbing work and installations performed under the permit issued,will be in compliance with
all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws.
(OFFICE USE ONLY) Type of License:
Perry)#G - ' ICS 1 OPlumber Et6sfitter `--id ��d��-
��7 ❑Master Journeyman tgnattre of Licensed Plumber)Gas Fitter
Inspector �+� ,
Fee:��` 62-
-� ❑Undil ted LP Installer License Number: �l�
❑Limited LP Installer
ROUGH GAS,WSPEC ION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
-29-1Cr-S Yes No
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TMS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: S PERMIT S
PLAN REVIEW NOTES