HomeMy WebLinkAboutBLDG-15-001365 gO'ol t 5>-4 tri et/ow-feet
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS f 2 eton.c.Jft_C % ---1OWNER'SNAME }I-1 ,af a d� 1
. G OWNER ADDRESS i �I TEG 9 7153/Y as-Vi FAX�— f
TYPE OR OCCUPANCY TYPE COMMERCIAL;,,. EDUCATIONAL J RESIDENTIAL
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CLEARLY NEW:,_.f RENOVATION:XI REPLACEMENT:=1 PLANS SUBMITTED: YES NO[,_f
AZI APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 ' 12 13 14 •
BOILER _J_I__1J—J__.I_J_LJ_ I_JJLJ•_I
- BOOSTER —J__I:— :_I TJ" l—J'J:—I_J J—I__I^J L__I
t CONVERSION BURNER _I._J•_J_i 1_1—J.____!'____1;____J _I_J'_J_J i
COOK STOVE- - J I :_f_'—1_J_J'—J —I_I_J _1 I
DIRECT VENT HEATERf t t _I J•—J-J-J' _J _(_J_J;_I _J
DRYER _1-1_J—J—I—JJ—I �• 1_I I� _J—J .
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FIREPLACE _II—J_J_i_J 1_1_I• t_J_,I—I_I_S_J
FRYOLATOR _J•_i_1_1•,____I—J _I_i I•_____!—J _—i —I_J_J I
FURNACE —J_J X I J -. I —J_I_I —J:-1 _I ____J ._I_I
I 1 GENERATOR —f _t I_I I__I—J _t_J.___11___I—J_—J
GRILLE _i ___I__LI I'_i i—I J —J—J__J _J.-1 —J--LI
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4 OVEN 11-•i /� J _ —J __I _I. _
c POOL HEATER _J_—_J_J_J _I _ n . •i�J—,J—I„_J
yROOM(SPACE HEATER I _I .. . I i—I. . �/'" �i I__rI ._ I _i
ROOF TOP UNIT ,J_I I I_I 0O_ �^ , .1•____!__j•_J _,_J
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v UNIT HEATER ! _J_ _ J e_ I_' I_1_I•_I; I
v UNVENTED ROOM HEATER f __J-_____1•____I.—.? I I____!..___i _J
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�i INSURANCE COVERAGE
,, I have a current liability Insurance policy or its substantial equivalent which meets the requirements of l GL,Ch.3�� 2YES NO4'�
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO RAGE BY CHECKING THE APPROPRIATE BOX BEL OW11 • ,A
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LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY �,J B'"' BOND--I�%I� O*-a
OOWNER'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.
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CHECK ONE ONLY: OWNER :1AGENT J
1 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 comW r�a/JXllpertlne sbn of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. rA//r/
PLUMBER-GASFITTER NAME i (vtl ,)u O
(ctt r'1 -i LICENSE#. Z7041 SIGNATURE
M MP MGF D JP$ JGF'J LPG' : CORPORATION a# 1 PARTNERSHIP rJ#I 1 LLC:,_J#r
.\ COMPANY NAME:; iit ICA-S4t,kn-) - - -iADDRESS; elf Mttw.m7 &- i
CITY n Aj Jf 0 ..._.... ...._... ..._..._.__ .._1 STATE TSL ZIP.07637_ STEL' S�D=S`12-rr _._._.1
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
/ "/ —)9 (2Ac$st Yes No
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THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
ELAN REVIEW NOTES
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