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HomeMy WebLinkAboutG-12-056 s7 • -, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING E _`!!__C CITY/TOWN:, C1 r/+re r''r9 ....J STATE:MMI. APPLICATION DATE:I ?�a//r J JOBADDRESS:. 7 wis OrC Rd • GOCCUPANCY TYPE: COMMERCIAL RESIDENTIAL PLANS SUBMITTED: YES NO0_, NEW ALTERATION REPLACEMENT❑ REMOVAUDEMOLITIOND t NATURAL&LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT-APPLIANCES-SYSTEMS 1 ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMRED TO FIVE(5)NUMERALS AIR ROTATION UNIT f— FURNACE: ALL TYPES 1-1 TEMP HEATING EQUIPMENT BOILER:ALL TYPES )- t GAS PIPING . THERMAL OXIDIZER , BOOSTER ( GENERATOR(STATIONARY ENGINE) ' TURBINE BROILER ILLUMINATING APPLIANCE fr UNIT HEATER BURNER: ALL TYPES —'I INCINERATOR JWATER HEATER: ALL TYPES ( v-• i CO-GENERATION UNIT — INDUSTRIAL AIR HANDLER EQUIPMENT OVER 12,500MBH COFFEE ROASTER ---1 INFRARED HEATER r—' (OTHER NOT LISTED2 • COOK APPLIANCE HOUSEHOLD - -J, KILN I GLORY HOLE I CRUCIBLE COOK APPLIANCE COMMERCIAL --( LABORATORY COCKS IIr, f. 7 9 s`r r DECORATIVE APPLIANCE �, MAKEUP AIR UNIT ( (I +rp-p `r c DIRECT VENT APPLIANCE —1 MECHANICAL EXHAUST EQUIPMENT I `I, \19 _ DRYER: ALL TYPES r--1 OVEN: ALL TYPES I i g 0v 21111 A FIREPLACE:VENTED/UNVENTED --I POOL HEATER FRYOLATOR I ROOF TOP UNIT L ....„ FUEL CELL —1 ROOM HEATER-VENTEDNENTLESS I t. ;or rr PLUMBINGl��/GAS FITTINGIFIRM INFORMATION t— CHECK ONEONLY NAME: G4 l� / 1 ADDRESS: /5 S ytm t r S ao anon Business t F- _ —'-_� Partnership Business t C m r-si- '�u 5 I STATE:QZW:R'/9O6 ] LLC Business I TEL: 731--7 V/-5/491 FAX:t 1 EMAIL: —I LJ©Unincorporated NAME OF LICENSED PLUMBER 1 GAS FITTER: INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES®,NO 0 If you have checked As,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy at Other type of indemnity 0 Bond OWNER'S INSURANCE WAIVER:I ant 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❑ AGENT Signature of Owner or Owner's Agent • r —� OWNER'S NAME: Sts//y A., 1/4 4 //91 1 TEL:I �..,,I FAX E 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: Penni Ilfri IrL1- 05-4 Qplumber Qdastiitter Inspector 1--- ❑Master [J.J/oumeyman �Du Icertsed Plumbed Gas Fitter Fee: H -- -� ['Undiluted IP Installer License Number: 3/994/ , 0 limited LP Installer s ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No D - I ( r , THIS APPLICATION SERVES AS THE PERMMT ❑ jek • If A 11/1tbaskica. 1951 FEE: S PERMIT ICit I12--056 PLAN REVIEW NOTES 4