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HomeMy WebLinkAboutG-19-7201 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `4 11=zV CITY ;5, y al..7. C C.- [ MA DATE Y T (PERMIT#N/Jt5%T-0©7 j JOBSITE ADDRESS; 1 u T C-1. C f 51-E. ¢ r _ 1 OWNER'S NAME GOWNERADDRESS 8�h _ .�� r;�'��1 Z 1 U _ E TEL {FAX' (. , TYPE OR OCCUPANCY TYPE COMMERCIAL;_] EDUCATIONAL PST J RESIDENTIAL CLEARLY NEW: RENOVATION:..3 REPLACEMENT:^I PLANS SUBMITTED: YES D. NO Li APPLIANCES 7. FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I__j: I______I__Li I' I L_J i__.___I__I�a_—I I I BOOSTER �. I,____I: I r- I- i ._ I-f( i j, .. i CONVERSION BURNER I i I I_ I. I; { 1 1 I . ... I I COOK STOVE ! i DIRECT VENT HEATER 1 _ 1 t__—I;—i., ' - I_I I _I I. I I s I f DRYER- FIREPLACE - -i :_ 1 -1 1 - 1 1- I. I j I 1 ..._ .1 1 1 FRYOLATOR _... .. - 1 { t I `- 1. I _ 1 `- I II 0 FURNACE - 1 I - I .._ I I - - I I I i I. ; 1 --_`I I I GENERATOR _ !_ .. . I .. i I ( I __ _.I_____I__ _ �I I ti . GRILLE —I__( — __.i I . t _�' _+ _ __ — : _ I (.- INFRARED HEATER _1____I_J �. 1 , -- 1 i.-J ! -- !_I I { _� {. LABORATORY COCKS I I -, I --___I i I I.._ `•__.__I I - I._ I 1 1 itMAKEUP AIR UNIT '.,_... ._ I � 1 _�._ I i OVEN I I (.....____1.____I I -i i -r- E.1 I___I e___E. POOL HEATER . 1 I I t—_I~ J :. # i:_...._1_____1 I I, I___ I 1 I ROOM/SPACE HEATERw, I I - ill I ROOF TOP UNIT 1 .1 r 1_ - 1 I ION `� i 2(1110 �1 ' I TEST :____.J .-.I.}t 1_ 1. _ i____ UNIT HEATER I I . - �- , I 0 - .- - , I ...-: UNVENTED ROOM HEATER I___-J: ! _____i `,_,_-•,.,I I I WATER HEATER ---- -- ___..._. I -1. 1 I 1. I 1�. I... _ .., 1 1 I I- i . I. OTHER 1 1 1 1. �1 , .. �� I • • I I 1 1 - .: . 1. .. I I-._�1 _I 1` I - { . - I top I I I— I I . I I _ JI I 1 -... 1_____,_I •I: i. _____..I I..�.... .. I I I._..__ _ ._. .� INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO ;_j I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li OTHER TYPE INDEMNITY .I BOND L_I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts Ge and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ;,''!,I AGENT ;.._ ATURE OF OWN OR AGENT I hereb rtify 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 pen-nit issued for this application will be in c p1i nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME -et,--,,-,-,--- ?o.;�.:. - y-•~ �^, LICENSE#P(3.5i(6 -j S ATURE MP_LI MGF'LI JP GF;-_Ii LPG' _ CORPORATION_1#` - 1 PARTNERSHIP #--- LLC #^ COMPANY NAME:' i.ADDRESS 3 2 C�1.v Y� . ..b( -- —CITY 1 c vAi S I. STATE in 0 I ZIP 0) -3 {TEL .77 k VC. �y(/ ( CELL' / e3� E AIL' plc ....►m 62i(-q S Plc..' CO r► ,FAX 7 _ . ._ .. i. CA/1.-S Asi