HomeMy WebLinkAboutG-14-885 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY Yarn/CUM I MA DATE 41-/./4/ IPERMIT# 1 tris
JOBSITE ADDRESS '1-B F"ldri4e ROZA I OWNER'S NAME YYl itr p h,(i
GOWNER ADDRESS S. yartrioni t. ITEL5a3'"lIio /fl5 IFAX I
TYPE OR OCCUPANCY Ty?E,. _ COMMERCIAL J _ EDUCATIONAL _J RESIDENTIAL<I
PRINT
CLEARLY NEW:J RENOVATION: J REPLACEMENT: ...._I PLANS SUBMITTED: YES_I NO J
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 I I __JJJ _JJ _JJ_JJ-.J
BOOSTER I J J _J _J _I J _._J J J ___J ._,J___J J_J
CONVERSION BURNER _J J _J J J J J __J _J ._,_J .__J __J J J__J
COOK STOVE _J I I _JJ _^J —J^J —JI ___I__I ___I_I__J_I
DIRECT VENT HEATER J _J _,J J J _ J _J J J J J ___J J J —J
DRYER _Ji _JJJ —JJ —JJJ —J -1 -1JI
FIREPLACE _J _J —JiiJJ—JJJJJJJJ
FRYOLATOR —J __,_J _-J JJ _J _,___J .__J ,._._J_I .._J J _J,J __J J
FURNACE _J ,_JJi —JTJJJ _I_l—IJ,JJI
GENERATOR J _ JJJJJJJJ—J;JJJJJ
GRILLE JJ —JJJJ —J —JJJJJ—J JJ
INFRARED HEATER iii _JJJJ .^JJJJJJ _._JJ
LABORATORY COCKS _,J ___J J J J _—J .1 J J J J J J J—.-J
MAKEUP AIR UNIT _J J _,_J -,_J J J J J J J J J J._. J..__J
OVEN JJJJ —J _J ^IJJJJJJ _JJ
POOL HEATER _J _iiJ_JJJJJJJJJ ___IJ
ROOM/SPACE HEATER ii _JJ —JJJ _LI J_I _JJJ—JJ
ROOF TOP UNIT _J _J _J _Jii _I _JJJ -1,JJ___J J
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UNIT HEATER _J J J J J ___J —J J ._J J J .. _J J__.._J J
UNVCNTJ UJZOOMHEAJER I./ _____I J J J J J J J J J ._J __i _J ____I J
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I Cy _____ff"a -__---..- I INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES IK NO _I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ZSJ OTHER TYPE INDEMNITY _J BOND Li
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 J AGENT _J
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and 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 compliance with all Pertinent provision of the
Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. 43,2,434-�
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PLUMBER-GASFITTER NAME Brunn Kali no IJJSif, I LICENSE# �r:�1 SIGNATURE
MP X MGF J ''``JP J JGF JLL LPG! __I CORPORATION J# I PARTNERSHIP J# Road
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COMPANY NAME: . ,-.. nJwc/I l f 1 'ianjJO-mil ADDRESS wZ, rneehnr� N6ase f load I I
CITY $DLrJ-h®/ of *hnm I STATE n1]l IZIP 02(59 ITEL, -µ3O' 4574 I
FAX7y2{237Ooat1 CELL I EMAIL kmeehanteaL 61 yethao, Com I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
?PLAN REVIEW NOTES