HomeMy WebLinkAboutBLDG-24-414 #B ?�' .0 , i3 -7;',-/./ j L,1 T,71 , W Dd
MASSACHUSETTS UNIFORM AP' - • ON FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY : '1 arrno U E'h I MA DATE: 11-(4 12 ( !PERMIT# 6 U I)C' - 2`I - "!I`I
ADDRESS r — I OWNER'S NAME ry n s r-rty n qv e r b� r)
G OWNER ADDRESS i ------
._-_-I TEL [FAX: -_1
TYPE OR OCCUPANCY TYPE COMMERCIAL;_) EDUCATIONAL RESIDENTIAL FX-,
PRINT
CLEARLY NEW:_j RENOVATION:_i REPLACEMENT:;XI PLANS SUBMITTED: YES r.J NO LA
APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —J—r_I—C__t __1_J—J__I _—I I LU ..Jj
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BOOSTER _ - I-____I. (, 1
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CONVERSION BURNER 1 . (_J I k 1,_ _J—J-___i—_I -J- ..I]:-J-_1
COOK STOVE —J I i'—j.-_t-J ______J __I___J____I-_I-J—I.-.J
DIRECT VENT HEATER -
DRYER•
I j_.____I:.___1 ! I-J I� . . t� __IJ
FIREPLACE I _ _... .I_�. I—J,�-_ _J -f. i_-J- _ f_J—J-J-J
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FRYOLATOR !-
FURNACE I--- . J .._ 1 1_I —J`- ! I -J____I I i_ _J ____1 1
GRILLE _GENERATOR I I .- i_ I_I . ---1_J__J_J_-1_,J—J__J ;
J I _J ! ____I___J-J. . .J __J !__.I,__1 ._._J
INFRARED HEATER - --I —r_J.__J I = (._J - '1___J _J_J-J_J__J
LABORATORY COCKS I ' J_ i—1_J -I !._J____J -__I__-.._1_J-__I__.J_J
0. MAKEUP AIR UNIT `;J'_f�J_-1 I_.__J ___11-____J __ J___J ___11
1 OVEN - I - I, I I- - I _—J J 1 1_ i, i1_U_. ___r ___J-_J I,
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POOL HEATER J_�_�J—J _—I_____I,_J I_1J R_ 1_ 1 V 1.. I_J
ROOM/SPACE HEATER - J I.- I I I_-__J f_ I it-- -- ! I I .4___I I
ROOF TOP UNIT __.I ; r______J i —
I I I ° _�i -____J _;- J-! I__S
TEST I {I 1 I ! J -___J._____I i J U r_ L t1/4,1
UNIT HEATER � . ! I :- _I --F- -t.--_.._. . '
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UNVENTED ROOM HEATER _._J_J i I i ;__-J,�13.I111 DIRE Att r 1L.NTI• j____1
WATER HEATER - -______ -•-- -;-' 1 1 . I—_.J__I I—J ' I 1
OTHER I I -i . . i r I _
—J J I I
1-J'-____I .__J
I l___1 1_ !�( �J 1 J. _I.
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INSURANCE COVERAGE
b I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES I-1 0 U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1V OTHER TYPE INDEMNITY ID 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 General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ,,_1 AGENT __-I
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 at Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f�
PLUMBER-GASFITTER NAME 1) nl} r T6 dn-e'_ I LICENSE# fere7I SIGNATUR
MP .. MGFJ JP J JGF A LPG!Li, I'J• 3y I PARTNERSHIPT-I# -
COMPANY NAME:/9`/A.//1 r ��/>` j�'_ !ADDRESS /'th .5-7 - - - -- - �- -
f I.
CITY lit Q.P,"1Ge Q- ..... . -.. .. I STATE' . ZIP- 29 73 !TEL 724(-c?"3. -Cj !
FAX CELL: EMAIL: --- __. --
C
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# -
FLAN REVIEW NOTES
•
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