HomeMy WebLinkAboutBLDG-15-000953 �0 it,/2
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_. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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?®ill_s CITY A rn.-. —'I MA DATE 9.3-/tr PERMIT#L46-'APCW 75-9
JOBSITE ADDRESS 2.o L4Xs.. R_Qa.' weft' OWNER'S NAME ( o r cies
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OWNER ADDRESS ITEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[] , EDUCATIONAL 0 RESIDENTIAL,
PRINT
CLEARLY NEW:® RENOVATIO :❑ REPLACEMENT:® PLANS SUBMITTED: YES 0 NOM
APPLIANCES 7 FLOORS-' -P, M 1 2 3 4 5 6 7 8 9 to 1 11 12 13 14
BOILER 11101111011.101011001.1rniilk
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BOOSTER fir-
CONVERSION BURNER aw at �i�i�E= I I� ... I `l... . .,
COOK STOVE i '' _ ` aa�r..
DIRECT VENT HEATER ��� �
DRYER a als SOS S
FIREPLACE $II riFURNACE ll=�_ ' � I � _ "rl� ,
S� _ .. :,
GRIGELLEATOR I` 3umMMl
INFRARED HEATERI 'rS]5f
LABORATORY COCKS ` r ,
MAKEUP AIR UNIT ' 1 I '1 �1 - y
OVEN 1 .,1* i 11 11 11 —.
POOL HEATER __ s ;, sur —
ROOM I SPACE HEATER it OEa,� LSS U� Is
ROOF TOP UNIT Mg Ii
f�YI S 1 Yf.c..._ .3_
TEST
UNIT HEATER a. J01l�i 1 .( IL'I I ,, .S'
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UNVENTED ROOM HEATER j ' S] I 'i S l
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WATER HALER Sitilfaralitilinaltilt,iiiiiiiiiiiiiM
.OTHER J. r_���.T - .A _ •**Ii1alitilia1SKS 11ONIC
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES gli NO U
HE YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - -
LIABILITY INSURANCE POLICY frit OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER El AGENT E.
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In tom with ell Pertinent provision o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 A'v ,t
• PLUMBER-GASFITTER NAME LIC, crajf'Qj(�1I 'LICENSE#�[ SIGNATURE ,
MPCal MGF0 JP JGFG LPGIDo CORPORATION D#�n1PARTNERSHIPC#I ILLCLJ#
COMPANY NAME: ' u s ADDRESS 7 III, • _ J V'1 A0
' CITY ahm/ .. STATE�f 1ZIP[194� TEL$*&S_ h al I
FAX L 1 CELL ,,,,� EMAIL ..._.,...�.,_____,... _ __ J
•
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
•
NI/b ,vo PeCRs &n.06, Yes No
/9-1- tc 1i *g y eb THIS APPLICATION SERVES AS THE PERMIT 0 0
/n:[4' t4 0'C "Laf v?/��Y FEE: $ PERMIT# !
PLAN REVIEW NOTES