HomeMy WebLinkAboutBLDG-15-002824 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
F�=" CITY ' MA DATE' 1 jl�� l �'PERMIT# � �S" CO% f
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JOBSITE ADDRESS[49 RIicQ>-}��a� ���,� i OWNER'S NAME �ce, Lcsp or (Y)af- l/--
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OWNER ADDRESS y _.. ..__ _. ...,..� .-_._ TEL.�;SC 36D y. cf1FAx
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL__~ EDUCATIONAL RESIDENTIAL
CLEARLY NEW:( f{ RENOVATION: _ REPLACEMENT:g PLANS SUBMITTED: YES , � NOI.
APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER11.111.1111-11111111111111.11111.1111111111-1111.11111111.1111111111.1111111
CONVERSION BURNER INSINS SNISMS
COOK STOVE SIMINIONN INSINN MN
DIRECT VENT HEATER 11111111111111111111111.1111111111111.111111111111111111111111111111111111111111111111111111111111111111111111
DRYER ISISIN.NW ININSI i '
FIREPLACE ` ` ; ' Una.NM
FRYOLATOR INIININIINNW SIIM111111 NNNNINN INS ININNIIINi
FURNACE 111.111.11111M an 11.11111.11111111111111.11111.1111ISINIMSI
GENERATOR
GRILLE ' M 'I 'MIN NM
INFRARED HEATER 1111111.111.1a «NS
LABORATORY COCKS Illnale N
MAKEUP AIR UNIT IMMISINSIN INS INININ ;
OVEN gok MIS NW MN.NWInI
POOL HEATER MA MN INN NW ON NO NS IINISMINNI NO 111.11
ROOM I SPACE HEATER MINIM raig NISION MINN NW TOP UNIT al111/1111111111111111111111111111Wwityw 1st__-
TEST NS EN aii NW INS NS MN IN WS'IS MN ME
UNIT HEATER i iei i�11, I;�luuiimem
UNVENTED ROOM HEATER IIM'—__NMI NW INISIN ONO'Elio NO NEMINSIN
WATER HEATER__ __.__.______.__-_.__._. iant 111111.11111111111111.1.1111.1111111111.11111110 INS
OTHER Ii ._ NM UM
MISINIMMIT 111NS1.111.11MNISNIS NM INS
NIS UN INS NW MS SIN NW IN MI INN NS INN NO MS ON
NW INN SIN INS—. —
SUM IMO NMI
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i NO Eli
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY `_ OTHER TYPE INDEMNITY r BOND L
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 AGENT 4..w
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 Peltinen vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. "
PLUMBER-GASFITTER NAME QNZp,L,5 LICENSE# 15 O3a fro,
MP MGF r:lj JP _71 JGF LPG! CORPORATION r # C Z bo 3 I PA SHIP._ #I I LLC! #'
COMPANY NAME IA`l 3,Nn5 qcs` 1./744� (ADDRESS L(y ..o��w C WA C►-ww. kit° •
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CIW I SD Oc4 S STATE? 144Ar o L (o o ?TEL I
FAX CELL :EMAIL!'
MAIL Ip��Tvctinicar� �► Cou�a 1-jwe
ROUGH GA§INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES.
Yes No
TITS APPLICATION SERVES AS THE PERMF ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
3
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