HomeMy WebLinkAboutG-12-315 4 _y
' J% MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING
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i _�!rir CITY/TOWN: o� �zeth �/�STATE:MA APPLICATION DATE: ///23J
JOB ADDRESS: t$ tZ74'i z 1
0 OCCUPANC TYPE: COMMERCIAL RESIDENTIA1421' PLANS SUBMITTED: YES 0 N9'
NEIN ALTERATION El REPLACEMENT!: REMOVALIDEMOUTION❑
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-1 FURNACE: ALL TYPES p TEMP HEATING EQUIPMENT
BOILER:ALL TYPES GAS PIPING J j THERMAL OXIDIZER
BOOSTER 7-1 GENERATOR(STATIONARY ENGINE) j TURBINE !IF
BROILER ILLUMINATING APPLIANCE J I UNIT HEATER
BURNER: ALL TYPES —1 INCINERATOR 1—i WATER HEATER: ALL TYPES
CO-GENERATION UNIT i INDUSTRIAL AIR HANDLER J-1 EQUIPMENT OVER 12,500MBH
COFFEE ROASTER —1 INFRARED HEATER J-1 (OTHER NOT LISTED? )�
COOK APPLIANCE HOUSEHOLD - 1 KILN I GLORY HOLE I CRUCIBLE 1 I
COOK APPLIANCE COMMERCIAL —I, LABORATORY COCKS I I r+ r, , ; [ A (H
DECORATIVE APPLIANCE IMAKEUP AIR UNIT I I ;D1 '", ''- 'i
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DIRECT VENT APPLIANCE 7-1 MECHANICAL EXHAUST EQUIPMENT I--1I i
DRYER: ALL TYPES ---j OVEN: ALL TYPES I L i it NOV Z3 1011 J
FIREPLACE:VENTED!UNVENTED POOL HEATER nn
FRYOLATOR ROOF TOP UNIT L ) qui inw;DEPT
FUEL CELL I ROOM HEATER-VENTEDNENTLESS 1 I.uY
�ffJJ PLUMBING/GASjFITTING FIRM INFORMATION /� / CHECK ONE ONLY etc W�( C
NAME:il44;n MCBrf�e- I'+ -. II C«)ilese (7c4&� corporation Businesst •.g
f� I ADDRESS: f—
CITY:11� C CCXA a MA i C 2b 73 —� 8Partnership Business f
STATE: ZIP:
1 �T __ LLC Business f
TEL� b-46_15 L. FAX:' EMAIL: km�PluMb®COmcCst.I ❑DBAIUnincorporated
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NAME OF LICENSED PLUMBER I GAS FITTER:
INSURANCE COVERAGE
I have a yurrent liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YEd NO❑
If you have checked as please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy IL 1 Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 192 of the Massachusetts General
Laws,and that my signature on this pert application mks thIS requirement
CHECK ONE ONLY
OWNER❑ AGENT ❑
Signature of Owner or Owner's Agent
OWNER'S NAME:J I TEL:`rr ----i FAX r 1
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) �i Type of License: �r/ � ,�
PernS# I 31 IJ I Et Plumber ❑Gasfitter �!
1---- ' /❑Master ['Journeyman
Signahue of Licensed Plumber)Gas Fitter
Inspector �7
— — --'I DUndiluted LP Installer License Number. J Jla� 1
Fee:'
0 Limited LP Installer
Y
ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPJCTION NOTES
Yes/No 4 A V -1(
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THIS APPLICATION SERVES AS THE PERMIT ✓2 0 /'Jit /2 tyetc_O�)
PERMIT
$ PERM # 7`
PLAN REVIEW NOTES
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