HomeMy WebLinkAboutBLDG-20-001682 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY ____._. _._---_-
_ MA DATE - - ---- .-_ PERMIT# (4PO-010
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JOBSITE ADDRESS S 6 el ry A AQ GWNE 'S NAME /" �/,/CI-49Et., Z/�$e
OWNER ADDRESS 1,-y TEL�' '/ Q - ` FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL__I, EDUC
PRINT A IONAL J. RESIDENTIAL
CLEARLY NEW:__ RENOVATION::] REPLACEMENT:VI PLANS SUBMITTED: YES 21 NO 1
APPLIANCES 1 FLOORS-4 -\ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER Lb AA I j 1 ) —J:__I—J—I_.1 J__1__I_1_1_1 1-1_J
BOOSTER —J--I I I 1_1_j'-]—J J._ 1 1—I—j_1
CONVERSION BU NER i I i 1 4: I_ 1 1 ___.1_ J__1 _a__I_ I
COOK STOVE __I I ._I_I_1_1_1__I:—J_____1___I_J J.-J
DIRECT VENT HEATER ._j_1 _1_1;__1, I____1_I __I__I I I_ ____I_1
DRYER'
FIREPLACE —I_J___-_I____I_1____1____1 - _I ._ 1 J II .__i_1_ ____1
FRYOLATOR ' —1-1.—i—J _ . I __. I 1 _____I IJ____ . .1
FURNACE ___I-J I I_____I) I I1 I I :-I ----1 I I
I GENERATOR i_ i 1 I I ( ;____1_—I___J___.1 I !_
GRILLE ___I_1�J_I I ....__. I`_J�J'__! J __1 I-__J __-__I_1INFRARED HEATER ____Ij''-J I 1__I_1 I-J —J—J____ILABORATORY COCKS I . _ I J _ 1--.-_-___I�f 1___1.____1._ -.__I____I_1___.1_J_J
itMAKEUP AIR UNIT I t
OVEN i I I I ' ____,1___.I I __J___J __ri pJ J____1I
POOL HEATER ____.1____I____1_J 1 I�f
I__I J__,._I I
I____I-J—1
ROOM/SPACE HEATER __ _i !_ I I I__._..J_ 1_,.—I. I _I 1-_-_.I_... I I
ROOF TOP UNIT _.._...1 .1_____` 1 ___ !_____.I_,_-_I ___1 I I 1
TEST _I i I i_ I -- _I I i I_ I I
UNIT HEATER I _� ( _..,J__I _I I___J: , I
UNVENTED ROOM HEATER ____J I __i, 1 ;___ I 1____I_ __j I ___J_,_,_,i I
WATER HEATER . .._ _ - __.. 1 I I I I�I I i__._. ___-_j I_____II I I 1
OTHER I I 1 I _ I I
1 1 I____I—1 _____1 —) 11
• . 1 ___I I I 1 I ;___J___I I-J____I_-J._.-1 __J
kb _ I _ 1 I_ ,___J___J_._._I ---1' .. .j-___J I_.____I___i___.1___.1_
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fhlt INSURANCE COVERAGE
tI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I$.NO ,J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 1-_1 BOND Li
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 -,_.I AGENT
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 Pertinent provision bf the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ( _
PLUMBER-GASFITTER NAME V\V f L K 03 r 1, Ie I LICENSE#1( VE I i SIGNATURE
MP __IMGF'J JP_ JGF LPGI CORPORATION i#' ,fro I) I PARTNERSHIP.E# - I LLC _#` I
COMPANY -
NAME V Y`_ r\ ( T \"S I ADDRESS 9 P u 5 r i c '0 r , -__
CITY \) r l v\0 t1�1 -. _ I STATE,(I ZIP 0.7...(0 73TEL TEL'-)7 L/ 3J Q_..9..7 t
FAX
CELL_ EMAIL' j'1 c-P/"`_ C -L i =i e�"' • -t 1,_ ('_13 An (.
Ep 2 6 /019
# i & (0
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yea No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT# C ���/Li `?�
PLAN REVIEW NOTES �'Iy` / /F
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