HomeMy WebLinkAboutBLDG-18-005052 SAP /0/9R c e / -per -L('
MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS I-1 I ING WORK
5- CITY !Town of yA Of -T7 I- ; MA DATE, '9 ARM PERMIT#1 P6�'Y-GV 57
JOBSITE ADDRESS! ,3 q [turn" NI 7P rTrrr rf OWNER'S NAME! ri-�r. C JC. M0,�CT r;!'
OWNER ADDRESS 1
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PPRE OCCUPANCY TYPE COMMERCIAL FDJ)CAT1ONAL i RESIDENTIAL
CLEARLY LY NEW:j RENOVATION:Li REPLACEMENT:+ PLANS SUBMI I I tU: YES D NO 0
APPLIANCES 7 FLOORS-+ BSM 1 2 3 4 5 6 7 8 4 10 11 12 13 14
BOILER
`lam 11111111111111-11111111111111M111ter: Mit MAMIE.
BOOSTER i .i i— i i' i
CONVERSION BURNER own.OM swim NE lifitIM am am am*LOS pm Mit
COOK STOVE iliiirAti ISM i NM JIM 1111111r 11111111 lr mas 111111f M 11111•11111,
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR _'_ineliall i ice i __ �_ ow—_—
FURNACE
GENERATOR ..iimiii.nig
GRILLE III III 1111,. ...„ . ,
INFRARED HEA I ER M.iiia=ail islowi i i i i i a wait
LABORATORY COCKS =MS—M AA L,ll 41)1 .,i J'.! � i• •
MAKEUP AIR UNIT i INN—MIK INN_MIL',Ularigi`EIr`,faili: htLa Lali 1i1: :ti J►t'a.J i
OVEN ill.i Ella Ai u Mt_•;Si±i.`ri�it 141!L I. 2IL '.�l:Wl_:-I'-
POOL HEATER , t ' , I :
ROOM/SPACE HEA I tit _.
ROOF TOP UNIT — - Inu=i-
TEST
ri
UNIT HEATER . __
UNVENTED ROOM HEA I ER •
WA I EH HEATER / __ / _ !
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES VIVO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY Cif OTHER TYPE INDEMNITY 0 BOND 0 L 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
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER d AGENT 0
I hereby certify that all of the details and information I have submitted or entered regarding this appliicalon are true and a to a my Imowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance a ° ant of the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASF TIER NAME J4, n in cde r.(le . LICENSE 1( ?e , - SIG TURE
MP a MGF C] JP® JGF 0 LPGI C] CORPORATION la# a FS 6F G!PARTNERSHIP OM LLC Dalti
COMPANY NAME4 ,ur-rnt'S rl de Plum-t q ec.4MCA ADDRESS' 1I ( 3nelivSe PGai-A
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CRY W. m. `r.rnc.-f1 • STATE[PM !ZIP ¢.g673 /TEL (5.0) -rig- 456( 1 •
F i~)740-67x51cELl 508)A4-37a41EMAIL11 Vim,C:p)V net 6 t rQr cac-4aee-4 1