HomeMy WebLinkAboutBLDG-23-9441 3Z. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1 f ' CITY LQ/NIQk - MA DATE 0. 2 (PERMIT#
JOBSITE ADDRESS, 77 /ScK./r 2G.g. _ (OWNER'S NAME PiG.1% 3 Cot kv‘..1•e%A 5.,1k.
G OWNER ADDRESS I TEL SA-790-12174.FAX- -
TYPE OR OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL J RESIDENTIAL 1
PRINT
CLEARLY NEW:,_) RENOVATION:') REPLACEMENT:) PLANS SUBMITTED:YES 0 NOIU
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER J.J_ I_1 J__I._______I —J_____I-J I_J_I
BOOSTER —J___I I_J-J—J—J 1 JI_—J-J
CONVERSION BURNER _I_J I I I I I _J_J I_J_J
COOK STOVE I__J I 1_I_J-J-J_I_I_I_I_1
DIRECT VENT HEATER I__J—J: 1 _J I __I ____J _J
DRYER• _____I_J_J—J_-1_____J—J—I I_J_1_
FIREPLACE I=I_I_J_1_J__J I____.I_J I_J—I-J I
FRYOLATOR __;JI_—J._J_ I,J'___I 1__I_J____j I I
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FURNACE ,__ I I____I=,1_; I_1—J ; 1----J --I I
1 GENERATOR __I_J__I__I_I _I-J—J—I I
GRILLE __i_J 1___I_I___J___I-J__I_J—1__J.__J—J_I
INFRARED HEATER _J_J_J_ I_J—J_I_ _I_J__I____I_J._I
LABORATORY COCKS __I _I ._._J___'__J_ _J_._I_—J_I_J__J__J
MAKEUP AIR UNIT —1___J____I__I_._l—J_I___I J I_.___i___I
OVEN 1._.__!.i 1 _—I__J-.___f I__J—J____I____ .__J_._J—_1
POOL HEATER __J_-_ —J I J —I__.___J.___J _I - J_— —.J_I __I__._J—I J_I
ROOM/SPACE HEATER 7._I___I I 1__ 1___1_1 J 1 __._.J- I I
ROOF TOP UNIT - I __ I_I__I_J I j_J I
TEST ___ —!,i J _ _i I__i_ 1 I
UNIT HEATER —J-_-J_„ 1 J_I_I --J_I_J
UNVENTED ROOM HEATER ___J__I—! i__I__I_._J—J_—J__J__J___ _J
WATER HEATER _ 4 J—1 i___!__J—1__!—_I— _ _J—I _J
OTHER I_I--j 1_I_...!—I___1__J I__J_ 1 1__- 1 1
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1_J-J_—I__—J I—!__-..I___I I._J__I I 1_I
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qt INSURANCE COVERAGE
C I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1' O _H-
I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ✓ OTHER TYPE INDEMNITY _I BOND 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 _I AGENT J
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 of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER-GASFITTER NAME tiD((A\S Y ( LICENSE#q��1 SIGTU .
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MP IMGF:LI JP J JGF A LPG!U CORPORATION 61241 (PARTNERSHIP:It 4 LLC #.
COMPANY NAME:141 T o I T¢k r,_ "ADDRESS If CaJmP
CITY W. (?Ia A ' STATE ZIP 6,7TT(TEL rit7q 3b-0r)gy 1
FAX CELL EMAIL &Von"6MAri(6�. (e✓h (
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AUG 2 5 2023
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:Tn'i c f PARTMENT
BY
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES