HomeMy WebLinkAboutBLDG-15-000019 ),(0 1H-0 y`l— /a
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM' AS FITTING WORK
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Alit-14CITY LnD MA DATE PERMIT I Z1406'11-1/0/7If1/019
JOBSITE ADDRESS : C ( > . - w OWNER'S NAME La b 4
GOWNER ADDRESS _ TEIi �� IFAX i
TYPE O
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OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL® RESIDENTIAL GQ
PRINT
CLEARLY NEW:® RENOVATION:. REPLACEMENT:Q PLANS SUBMITTED: YES® NO1I
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 111.1111110111SIMMOMMISMOMPOOSSISONEMISJOIN
BOOSTER 01.00V -- 10010101111101101117-
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CONVERSION BURNER 55SPOIROPOISS WSW
COOK STOVE .s - is S [S*Ir !1 '
DIRECT VENT HEATER1i1iiS arsitiociiiiiiii
DRYERlmi Al ii s si t 1a1 �� 1. 1� J�
FIREPLACE u ) al 011111100000.1-91.1r_ .
FRYOLATOR ; �'
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FURNACE ,' ;'1 I 1S5I j S
GENERATOR 0.01110110.11000M110.0100.101,Mignialiellinaltalliti.
GRILLE wismissirsomaiiirwassisioassiiimili
INFRARED HEATER110111111011.101101a.00.10001,110,0100000S00001.010.
LABORATORY COCKS !` j {f 'j ` ; � J
MAKEUP AIR UNIT0.011.0001101a10111111.110- •
OVEN illielaili-Mtlinlialititallilinallani, 1101101._
POOL HEATER soresinstair oisi ;r . j' I [ 'Imi ] n, '
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ROOM/SPACE HEATER ;�i (II_JPJ( alj IO. IE 'I , j
ROOF TOP UNIT __ ][) ISION I { 1101111
TEST 1111.01, iii10. 1
UNIT HE_LER ry�jyi 1 11 �yyyy�� isiria � 11 ,r l'r 'imotai
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11� 1 '�Iti a r LIRA I—•N iiS 15118 l iloirlII ilit
WATER osio1sat `smis'US
PEER Int ' .e4 all001000001,100011001a;0. iiiiiiiiii•impao at
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sato RIOMMICISSIENSalKilltatailillicSatillon
c INSURANCE COVERAGE
I have a current liability insurance po icy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES XI NO Ca
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY 0 BOND 0
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 0 AGENT 0.
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details end information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In com•I._••:with ell Pertinent provis'on o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 11.1 , ^J�03 ' , LICENSES ( r`..II ....s. SIGNATURE k. 1 t
MP FM MGF 0 JP Q JGF Q LPGIQ CORPORATION Q# 1 PARTNERSHIP[ #e_,S_J LLC ad ,j
COMPANY NAME:G "Y.S w�L .QY,i«U�dLIJ 1. . 4 ADDRESS 2\ a, • _I _N/ �-
CITY �.e1 I .LY„ltisr [.5�... . STATE rI 5f ZIP , V1 TEL w - 1. . 0',
FAX I CELL, EMAIL — I
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ROUGH GAS INSPECTIONNOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
i Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT it
PLAN REVIEW NOTES