HomeMy WebLinkAboutBLDG-24-402 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'Irf,►r�" CITY 774/-" let y I MA DATE: 7- t- 2f I PERMIT# gL')G -1"- 14)-4-
JOBSITE ADDRESS "'�' 1-t Ir'' w (pr tot €_ r '
OWNER'S NAME t-c.(3�1z ,,, 4 1 c rc v1
GOWNER ADDRESS i I TEL: ,FAX' t
TYPE OR OCCUPANCY TYPE COMMERCIAL;] EDUCATIONAL =J RESIDENTIAL r
PRINT
CLEARLY NEW:J RENOVATION:J REPLACEMENT:J PLANS SUBMITTED: YES 0 NO LJ
APPLIANCES 7 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _1___f_____i._ _t__J,__1 J,_I—_I_.( f'_I'_1_I
BOOSTER —J,—J I- I t C—1— —__f—_I.—t—I—___I—I f
CONVERSION BURNER _J 1_J I f f_}—J._ 1-_____I____I_1____1 . I I
DIRECT VENT HEATER _J____I —J_f__i____I____1„,_ f_I_1___J — . I
COOK STOVE —J -1—I-J—r i�-� -_ J—� _J
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DRYER' J—l.—J_____II—�__1 —J. _I___1 i___I
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FIREPLACE FRYOLATOR I ( i;_J`'� I—f —J •-_I ___I_1_-_I _ I —_(
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GRILLE J 1 I, _I . I — __I—f I I _-I_I __I,—_.I —J
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INFRARED HEATER - _J -- __J ___J'__I__I . .I
LABORATORY COCKS I- —J.—_j I— I I . _I-J I_1_1 I—_J_I I
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ROOM/SPACE HEATER - -..I . I_ __I I I ! I i _ - 1 T 1 I I I
ROOF TOP UNIT _. I i I i _ I__J___J—_I I-- i-_J i
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UNIT HEATER I ! 1 . I 'r . . I__J 1-_J I;_I ___J
UNVENTED ROOM HEATER I, I ? _ i ( J. J i BUILpING T))Ef'Ali/rMEIUT
WATER HEATER - - ___ __ _ I I I I i I #.- -i= I f f
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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 lib D.
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY -�-f----. OTHER TYPE INDEMNITY .-_-_I 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 ,-1 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 of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME -_ ` ~ T ,- �� . -
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MP MGF JP 3 JGF',f LPG!J CORPORATION- `J`23`/ f PARTNERSHIP_I#- I LLC:J#^ 1
COMPANY NAME:' 9// c7/�r tP�f1` /C I ADDRESS //lri,/? .�%r-- -- — - - — — --
CITY i{/. Qf,Y1 e d1 I. STATE/f/7 ..I ZIP U if TEL �7 y-,,r� -62
FAX 1 lCELL I EMAIL - _ -r
ROUGH GAS INSPECTION NOTES THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yea No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE:$ PERMIT#
PLAN REVIEW NOTES
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