HomeMy WebLinkAboutBLDG-15-002986 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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y� CITY I ��Mn� J MA DATE 11 12119 I PERMIT#BCG--1.S6029d
JOBSITE ADDRESS 7 }{1/411 tcAvtJ cif 'OWNER'S NAME Ar`t h Coop f v
, G OWNER ADDRESS TEL 11 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:E] RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO®
APPLIANCES 1. FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER I I J j
CONVERSION BURNER
COOK STOVE _ '
DIRECT VENT HEATER
DRYER ii
FIREPLAC
FURNACES ass
FRYOLATOR
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GENERATOR IIIIIIIIIIIWIIIIIIMIIIIIIIIIIIOIIIIIPIIIWPIIIIKIIIIIIIIIIWIIIIIIIIIIIIIIIIIIII
GRILLE _
INFRARED HEATER ___ __
LABORATORY COCKS
OVENUP AIR Wallii1111111....wass
POOL HEATER 1 t
ROOM/SPACE HEATER11 1 , i
ROOF TOP UNIT ,/"
TEST r '1, / r -r Jr '1— , r- p [--
UNIT HEATER �� ,I�... i Ien
UNVENTED ROOM HEATER ;, iANN
WATER HEATER /
OTHER I ] I 4_
INSURANCE COVERAGE 1 , NT,/ lig 71114
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL'.Ch.142 YES gi NO Q
I c677.1 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW s,,_CJ7.,:i'
LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY ❑ BOND 0 yTC)r'
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
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)-.vision oft / e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAMEAptly-1wS 1{655-4 ka I LICENSE# /ZV' _ SIGNATURE
MP rig MGF❑ JP❑ JGF Q LPG!❑ CORPORATION®#X3365 PARTNERSHIP❑# LLC❑#
COMPANY NAME: AS_N< yn(Ct&Aw+'t4 N L ADDRESS 30(.1. &ha Jotwy_ 0'V' Dv. _ .-. .
CITY RftWS-[til STATE KA ZIP 0 26;?./ TEL (Sag)-237-9677
FAX ,CELLLSAA, EMAIL MIS41 en[1,t,11mhtCivil e N0[11mm,�l,coli t
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,op ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
R&# eer- 64S CYC Z-R# goie Yes No /y
p S !// //� THIS APPLICATION SERVES AS THE PERMIT 0 0 /7/0 crop/vigor:-
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igort "* (n 9' otc y/3/5- FEE: $ PERMIT# /Pui9O a-n 0,22-i2,$- ea/03—
PLAN REVIEW NOTES
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