HomeMy WebLinkAboutS-20-1347 ,` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS`29 RC. ril- 11 (T6 I1;2.:i-OWNER'SNAME (/"(; , ,v�� }-q �-
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TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL;_l EDUCATIONAL J RESIDENTIALA;
CLEARLY NEW:=J RENOVATION::] REPLACEMENT:>41 PLANS SUBMITTED: YES 0 NO LJ
APPLIANCES 7 FLOORS--0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —J—J__I_J 1 —.J:.—J—J_J I t —J
BOOSTER .-1____1:____I —I_I'____I-' J_I. . I t.
CONVERSION BURNER .-J._J.._____I I 1: I.J t-_I__I: 1 f:_} j
::___ICOOK STOVE : J / .I I`_J- _J_J 1:.-__ 11_i i -i
DIRECT VENT HEATER ._I__ _ '_J; I ;-J fJ j.� J..
DRYER• :J—J:J.—�_J: ... . I�._ .- I .... ..I-_. .._� .... I I._—I.J—J
FIREPLACE �__J—J__L—_ ..�i._____I-____I
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FRYOLATOR ---I -1°J -s: .. t_1-..... _I_f. 1 _. i—1-—.I—1--1
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1 GENERATOR I..��.. i.. . . I I GRILLE !i. 1:._�.T_� I ._,.. I:��:____.!._— j _-I:.__1-J____ I
INFRARED HEATER :____I t J.—J I .�1:—J _ I-_J J__I'_J__J I
LABORATORY COCKS __I .1 j ', I . ... I I I r J L__II___ ___..._I.—_._.I_I_—__I_J
it MAKEUP AIR UNIT - 4 .... 1__I_—I_J i_J__J___J I I___I L_,_ J
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POOL HEATER _J____'I.�.J—J�I____J I_ _—I I�J. 1 J _J___J--i
ROOM/SPACE HEATER _,,,___I _.. I__ J _ .I —
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ROOF TOP UNIT „_._I i I____.__:1
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TEST I_____I I I t I -J`I_I I I I--I I
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UNVENTED ROOM HEATER __I_J I i I 1_ I j i ____J_,_,•—i__I
WATER HEATER ------- ---_..._- I .. _ . I... ... 1 ! I _ I ,___ _
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OTHER I_J' I I:___J- __I:—J_—I I_._._J____I__I__I _I I_.I
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INSURANCE COVERAGE t I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES g NO :11.
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1 _ OTHER TYPE INDEMNIFY .jj BOND [If
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 ,—_1 AGENT UI
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 Peal, pro 0--ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Ali csn, LICENSE#) 3"9I " � - _ E
MP MGF'._.1 JP J JGF:- LPGI _1, CORPORATION ` f PARTNERSHIP__Ili LLC�#i f
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COMPANY NAME: .-f4i K C itt P Ili'4 I,t)Lr I.ADDRESS (c,•Z°I b Le IN
CITY I. STATE vi- I ZIP O21-I' TEL -3--74 Z/- r3 z 4( f
FAX 1 CELL: EMAIL:_ Z - V`IP (D 1T 1�'t/4, , � - E
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
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FEE: $ PERMIT# 144Z,./f•
PLAN REVIEW NOTES
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