HomeMy WebLinkAboutG-12-092 _� MASSACHUSETTS UNIFORMy/ZAPPLICATION FOR A ER`MIT_TfDO-GAS FITTING
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C n'= CITY/TOWN: STATE:M PPLiCATIONDAT .
JOB ADDRESS:W...,..............„.1 AUG 2 2 2011
GOCCUPANCY TYPE: COMMERCIAL❑ RESIDENTIAL Pl8N3SUNMITUE . PS 0 NO
NEW0 ALTERATIONS REPLACEMENT REMOVALJOEMOLITIONE
V 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 nn TEMP HEATING EQUIPMENT r.
BOILER:ALL TYPES --j GAS PIPING J 2 I THERMAL OXIDIZER (—
:
BOOSTER 7-1 GENERATOR(STATIONARY ENGINE) J J TURBINE r—`
BROILER —1 ILLUMINATING APPLIANCE rr UNIT HEATER
BURNER: ALL TYPES —1 INCINERATOR 1-7 WATER HEATER: ALL TYPES r
CO-GENERATION UNIT —7 INDUSTRIAL AIR HANDLER 1-1 EQUIPMENT OVER 12,500MBH
COFFEE ROASTER —1 INFRARED HEATER 7 -1 (OTHER NOT LISTED? •
COOK APPLIANCE HOUSEHOLD —1 KILN I GLORY HOLE I CRUCIBLE r—_
COOK APPLIANCE COMMERCIAL —1 LABORATORY COCKS -1
DECORATIVE APPLIANCE —1 MAKEUP AIR UNIT rr
DIRECT VENT APPLIANCE '- 1 MECHANICAL EXHAUST EQUIPMENT r-1
DRYER: ALL TYPES —I OVEN: ALL TYPES I
FIREPLACE:VENTED I UN VENTED I. POOL HEATER I h J
FRYOLATOR ROOF TOP UNIT I
FUEL CELL I ROOM HEATER-VENTEDNENTLESS I
�w�PLUUMMBIINNG/GAS FITTING FIRM INFORMATION (CHECK ONE ONLY
NAME: gitrti 4SaIflo"% ADDRESS:LS0+�,!1O€ 1 /r/_- r--r"orporation Business S
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CITY:l ed/r Ufi~ f STATE:EZIP:
r LLC Business/
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TEL: 1�'Pwr4 FAX: EMAIL: '� f DBA I Unincorporated
NAME OF LICENSED PLUMBER I GAS FITTER:
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES❑ NOR]
If you have checked yfri,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 WANER: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 waaives�this requirement
>crrl.L1VJt-) krAde 2- � Z OWNER®CHECK ONE ONLYYAGENT
Signature of Owner or Owner's gent
or
OWNER'S NAME: f 1 TEL:ET. 1 FAX(
I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application Is Uue 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: / /
Peng II _ 1 C-- -c ❑Plumber EfGasfitter i`
❑Master ❑Journeyman Signature o Licensed Plumber I Gas Fitter
Inspector 7'}� �i J22i
Fee: `&—01 GY.-,--..r�.._J ❑Undiluted LP Installer License Number
0 Limited LP Installer
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