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HomeMy WebLinkAboutG-12-039 t + MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING =_in'= CITY/TOWN: efer/oli 7-22-/, _,a,i_ STATE:MA APPLICATION DATE: JOB ADDRESS: (9 Fxe7?.e GOCCUPANCY TYPE: COMMERCIAL RESIDENTIAL IE PLANS SUBMITTED: YES 0 NO❑ NEW❑ ALTERATION!: REPLACEMEN12 REMOVALIDEMOLITION❑ r NATURAL&LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT-APPLIANCES-SYSTEMS 1 ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(S)NUMERALS AIR ROTATION UNIT j----1 FURNACE: ALL TYPES TEMP HEATING EQUIPMENT r BOILER:ALL TYPES -----1 GAS PIPING r THERMAL OXIDIZER 1--- BOOSTER -----7 GENERATOR(STATIONARY ENGINE) j TURBINE r___., BROILER ILLUMINATING APPLIANCE T^ UNIT HEATER BURNER: ALL TYPES INCINERATOR I— WATER HEATER: ALL TYPES CO-GENERATION UNIT -----1 INDUSTRIAL AIR HANDLER I-1 EQUIPMENT OVER 12,500MBH , COFFEE ROASTER ---1 INFRARED HEATER I-^ rOTHER NOT LISTEDl COOK APPLIANCE HOUSEHOLD —1 KILN I GLORY HOLE I CRUCIBLE 1-1 COOK APPLIANCE COMMERCIAL —1 LABORATORY COCKS p DECORATIVE APPLIANCE 1 MAKEUP AIR UNIT I-7 DIRECT VENT APPLIANCE MECHANICAL EXHAUST EQUIPMENT r1 DRYER: ALL TYPES —1 OVEN: ALL TYPES (— FIREPLACE:VENTED IUNVENTED I POOL HEATER FRYOLATOR I ROOF TOP UNIT ( FUEL CELL ,_1 ROOM HEATER-VENTEDNENTLESS I I PLUMBING/GAS FITTING FIRM INFORMATIONCHECK ONE ONLY NAME: AaP/VW m ants6ic1 ADDRESS:1ra-C4 tern zj OCorporaUon Business# nPartnership Business it CITY: /141-7 ,-;;;;Zi ./.:1-7-7/i. 1 Lid; ZIP:L O Z 6 c/e � LLC Business t I I TEL: -77%fg6.4184 FAX:I 1 EMAIL: --~ Ji {DJDBAIUnincorporated NAME OF LICENSED PLUMBER I GAS FITTER: ay, , ; /01- elleti INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES El_NO❑ If you have checked yo,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy©- Other type of indemnity❑ Bond ❑ 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❑ AGENT ❑ Signature of Owner or Owner's Agent OWNER'S NAME:r 1 TEL:{� I FAXr 7 1 I hereby certify that all of the details and Information I have submitted(or entered)regarding this pent*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: Permg# - - 3a ['Plumber ❑Gasfitter ���. , `e'e` n r I Signature of Licensed Plumber ay G�s Fitter Inspector. � .. ---� �,A LMaster ❑J n (g IL p , . Fee:1 0 1 ❑Undiluted LPInstaller £ ILlieenseNY rr6er: z9r�C' ❑Limited LPInstaller ,II I 22 2011 .--J Dy }L(y�!� df(/�DEPTp� ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT • PLAN REVIEW NOTES i r a