HomeMy WebLinkAboutG-12-159 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING
' ='7111'_ CRY/TOWN: Lai i.:r� WVali STATE:MM. APPLICATION DATE: J
1 �eltttttt r
JOB ADDRESS:r''T3
GOCCUPANCY TYPE: COMMERCIAL RESIDENTIAL_ PLANS SUBMITTED: YES NO El
NEW 1:1 ALTERATION REPIACEMENiM REMOVAIATEMOLITION❑
r NATURAL& LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT—APPLIANCES—SYSTEMS 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS
AIR ROTATION UNIT 1 FURNACE: ALL TYPES LI TEMP HEATING EQUIPMENT r--
BOILER:ALL TYPES ( GAS PIPING THERMAL OXIDIZER — "
BOOSTER --1 GENERATOR(STATIONARY ENGINE) r ' TURBINE ('....m'
BROILER —7 ILLUMINATING APPLIANCE ( UNIT HEATER
BURNER: ALL TYPES —7 INCINERATOR JWATER HEATER: ALL TYPES -
CO-GENERATION UNIT —1 INDUSTRIAL AIR HANDLER IEQUIPMENT OVER 12,500MBH
COFFEE ROASTER —1 INFRARED HEATER I. MTHER NOT LISTED1
COOK APPLIANCE HOUSEHOLD —7 KILN I GLORY HOLE/CRUCIBLE rCOOK APPliANCE COMMERCIAL —, LABORATORY COCKS 1-1
DECORATIVE APPLIANCE ,,,=,
, MAKEUP AIR UNIT i----iDIRECT VENT APPLIANCE , `t MECHANICAL EXHAUST EQUIPMENT —7
DRYER: ALL TYPES --I OVEN: ALL TYPES _...7.
FIREPLACE:VENTED!UNVENTED ` I POOL HEATER 1
FRYOLATOR I ROOF TOP UNIT
(
FUEL CELL I ROOM HEATER-VENTEDNENTLESS , 7
P : G/GAS FITTING FIRM INFORMATION CHECKCHIONE ONLY
NAME: w 7—, /,damJ are ADDRESS:Gj / A —_7 �,®Corporatlon Business/
1�` //%�-------1 q Business I
CITY: STATE: I P: . I ! �e/7/a FX: T :24 I ' 9Pflershfp
DBLLBusiness►
! � � dolt: '_� �-- ❑DBAIUnincorporated
NAME OF LICENSED PLUMBER I GAS FiTTER:
INSURANCE COVERAGFi
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 AI please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of indemnity 0 Bond 0
OWNER'S INSURANCE WAVER 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 item this requirement -
CHECK ONE ONLY
OWNER❑ AGENT
Signature of Owner or Owner's Agent �7
OWNER'S NAME: 1TEL: ,�. . ..I FAX
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 ON—LY)) Type of License:
Permit# f 42 - I / 1 a � er ❑Gasfilter /2O72e ( / --�
----1 BMW 1 - <er ❑Journeyman Signal of Licensed Plumber I Gas Fitter
Fee:�N. ~ _ --1 ['Undiluted LP Installer R EeOeettibt: � 7 `//
❑Limited LP Installer
BUILDING DEPT. •
BOUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY �1 FINAL INSPECTION NOTES
(�
Yes No I - d 2 -it r-iAna / o/6/C_.
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT
PLAN REVIEW NOTES
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