HomeMy WebLinkAboutBLDG-15-003263 /77 )0 pAi R C e 1
i' .. MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FfTTIN G WORK
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JOBSITE ADDRESS IVA 1.4' ViCia C)-- Ro*V (OVVNER'S NAME I R0,9)(nr-A;:i0 I
• G OWNERADDRESS I I Tal (FAX • t
TYPE CIR
OCCUPANCY TYPE COMMERDIALD EDUCATIONAL IJ RESIDENTIAL EW
• PRINT
amARLY NEW:El RENOVATION:0 REPLACEMENT at7" PLANS&ISM'I;w: YES ID NO0 •
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 • 8 9 10 1 11 12 13 14
BOILER
BOOSTER .11• _-_linli /MS ell*.MIK I • W: .
CONVERSION BURNER _ j
DIRECT VENT HEATER
DRYER taN i - -- (
FIREF'LACE I MI • I
FRYOLATbR ' •_ 4 _ JUNE , _ - IISS' _
GENERATOR - -• - -1
GRILLE •
INFRARED HEATER I 44 _......,
LABORATORY COCKS , SINE
MAKEUP AIR UNIT NI • 1-
OVEN
POOL HEATER ' * - I ' -11tatilli_ I
ROOM/SPACE HEATER ' ._ 1 _ FINAL TEST AND INSPECTION '
ROOF TOP UNIT •
•
TEST - _ II • Within five(5)days after plumbing work is
UNIT HEATER 4 sufficienffy advanced so that Principle No.6 In
UN vpii-F,p Rooftuipn-: D i _ _ .., 248 CMR 10.02(6)Is satisfied,the plumber
WA z'' :Ls a' - -__ —--- . AMOK'S alltillk who performed the work shall notify the ,
OTH m' ' t ' f• . _, _ - , inspector.
nr1 o 0 1111 le f L L______J • Applicants Initials:
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ri ill r :cpaTtl(ThiT , t ' 1 • .. ' -
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• Dv - - mai _ INSURANCE COVERAGE • .
I have a cement liability insurance policy or its substantial equivalent with meets the req
of MGL Ch.142 YES ETWo 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COBY CHECKING THE APPROPRIATE BOX BELOW
ErE
• LIABILLIYINSURANCE POLICY OTHER lYpE INDEMNITY 0 BOND 0
• OWNER'S INSURANCE WAIVER:I am aware that the Scams done net have the Insurance an/erase required by Chapter 142 di the
Massichusets General Laws,and that my signature on this permit appUmstion waives this requirement
• • ' CHECK ONE ONLY: OWNER Q AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby teddy that ell Drina details and Information I have&Wanted or entered regarding this spiton ere bus and=nate to the best of my Icnowledge
and that all plumbing work and Installagom performed under the permit Issued Tor this epplicafion will be hi compllanoe with all Pertinent provision of the
klassachusetts Slate Plumbing Code and Chapter 142 of the General Laws. . •
PLUMBER-GASH I I kit NAME I e rim-to-os 1 LICENSE SIG TURE
• MP O MGF fp JPFJ JGF Ei LPGIO . CORPORATION p#1 (PARTNERSHIP phi I L1C al • I
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COMPANY NAME1 OD A-7 nt 774°tic. I ADDRPS1(O70 Or-J) ISA.s.s RAO ta •ibfl 1
' CfrY I 000 Air, • I STATE) nlit 110>e--;56 (TEL I CA 7-9C-19-00 2 frFAX ICr ( •
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