HomeMy WebLinkAboutG-12-023 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING
"�- CITY/TOWN.iSov1 J STATE:MA APPLICATION DATE: ///e/- 19// J
JOB ADDRESS:/63 Cf 0' ( ft +
0 OCCUPANCY TYPE: COMMERCIAL CI RESIDENTIAL(3 PLANS SUBMITTED: YES 0 NO A-
NEW❑ ALTERATION': REPLACEMENTDREMOVALIDEMOLRION❑
r NATURAL& LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT-APPLIANCES-SYSTEMS Y
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS
AIR ROTATION UNIT r1 FURNACE: ALL TYPES I TEMP HEATING EQUIPMENT
BOILER:ALL TYPES —_L GAS PIPING 1— THERMAL OXIDIZER 11.1
BOOSTER ---1 GENERATOR(STATIONARY ENGINE) r"` TURBINE fal1
BROILER ---1 ILLUMINATING APPLIANCE J----/ UNIT HEATER
BURNER: ALL TYPES INCINERATOR J— WATER HEATER: ALL TYPES F
CO-GENERATION UNIT ( INDUSTRIAL AIR HANDLER J I EQUIPMENT OVER 12,500MBH
COFFEE ROASTER INFRARED HEATER J-1 4-OTHER NOT LISTED-I
COOK APPLIANCE HOUSEHOLD KILN I GLORY HOLE 1 CRUCIBLE F-1 11111,
COOK APPLIANCE COMMERCIAL LABORATORY COCKS J1 Reconnect Mea) MS Mete /
DECORATIVE APPLIANCE -1 MAKEUP AIR UNIT 11
DIRECT VENT APPLIANCE _1 MECHANICAL EXHAUST EQUIPMENT I
DRYER: ALL TYPES -----1 OVEN: ALL TYPES 1-1
FIREPLACE:VENTED I UNVENTED I POOL HEATER (-1
FRYOLATOR I ROOF TOP UNIT
FUEL CELL I ROOM HEATER-VENTEDNENTLESS 1 `,
PLUMBING// /GAS FITTING FIRM INFORMATION CHECK ONE ONLY
NAME: 4 -ocif hA J,7 ' s/�,T ADDRESS: GY ado-cryt• ['Corporation Business/
�� -�y- �'��7 �- 7Partnership Business/
CITY: YO -c 1 i STATE:[SIP:�..Qagi2. i -.1 LLC Business/
TEL: &7 a2a12s I FAX:MISS EMAIL:.4055'0.1,6-3;;;70/(94.Cei;;1 El BA I Unincorporated
NAME OF LICENSED PLUMBER 1 GAS FITTER:
INSURANCE COVERAGE
'LI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I:V If you have checked tea please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 137 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 permit application wafer this requirement
N CHECK ONE ONLY
l OWNER❑ AGENT 0
Signature of Owner or Owner's Agent 7
OWNER'S NAME:1 Ga/7/r,- r�G/�tr'/>- 1 TEL: I FAXE 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 La
(OFFICE USE ONLY) Type License:
Permj1/ - . Plumber ❑Gasfitter
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4n' ' I it !9S`' Master J yman_ Sig•.tore of Licensed Plumber 1 Gas Fitter
Inspector /� �
1 ❑Undiluted LP Ins II E C �Liien$e�Vu
Fee:�Y
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❑Limited LPInstall JUL i 2311
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