HomeMy WebLinkAboutBLDG-17--002619 ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1_f= CITY ydTP7OLJ .. _.-_-_ ------ -----i. MA DATE//-`y'7 1 PERMIT# /3�/)6-/7-0,o'�CP/7
JOBSITE ADDRESS'- R7� ,4 s Ear LAJ,oy (OWNER'S NAME D j r/? 1
GOWNER ADDRESS t��NJ- -- -
TEL _ __ FAX' �:
TYPE OR OCCUPANCY TYPE COMMERCIAL;1 EDUCATIONAL }/
PRINT J RESIDENTIALYd
CLEARLY NEW: RENOVATION:J REPLACEMENT:—1 PLANS SUBMITTED: YES-3 NO;
APPLIANCES 7 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER LJ I: I—__1—____ I, I I_J_1 ! I J .-.. I
BOOSTER _I 1_! 1 ,.. . .I_ _J 1____f.--_f_�I_____1—J
CONVERSION BURNER III I r. I I ;- 1. 1 1 ! 1 !
COOK STOVE ! / I !-_J f—1—i—_ _I_1__1. 1 1 1
DIRECT VENT HEATER i .1-
I—E;__j _____1
1 1�j _ I I 1.. I
DRYER .
_1____I is I_1 I —_J 1 1 ! 1 ! i
FIREPLACE I
0 FRYOLATOR ----, f._J __I 1 I 1 -i __1_-__I.__
FURNACE __ I 1—J- I - 1 I I 1--J --'-- J ._.—(
1 GENERATOR 1_ .. . I I I i . I f I I I
GRILLE ____i_l;__J _._._.__1 I__; _ __i_._._`i ' -__.__!.__J .1 J
INFRARED HEATER -J_J _J 1 1 1—1 1.--1 —J _ _J
LABORATORY COCKS 1 I 1 _ ! .
c MAKEUP AIR UNIT : _I __.1__ 1 I 1_,- f 1 I I I__ 1Y i s
OVEN 1 I . 1 W_- r.__�I _.I _1 _ I .1 ....____! -_YJ _..-__I I
POOL HEATER _____! 1_____! I._ __I_._..___I _._j•___1" I__..J____,'_U1_ 1 1 1
ROOM I SPACE HEATER - _ ..I _. i - 1 . .. .I I_ _ I- 1 -
ROOF TOP UNIT I �--
TEST - 1 t i I I .
UNIT HEATER i ; _..__I ' . .
UNVENTED ROOM HEATER ____.J__; ! ______1- ._
`__ _._.i I __ __j 1_.___1 _.____j �__�____1
WATER HEATER . --- ___ - I__I.. i 1__1_I 1___.I _J 1 1 1__ 1�J I
OTHER - I I _,I _I ... 1 _1, 1 I_._. ..I
Illill : I
' _ ; I '- ____ -- -—_-1 _ I - i
INSURANCE COVERAGE /
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4 NO '-'1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J OTHER TYPE INDEMNITY BOND III
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 '--II AGENT .0
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 : he best of.. knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp!iai •-. ne. • ovi '.n of the
Massachusetts State Plumbing Code and Chapter 142 of the eneral Laws. /
PLUMBER-GASFITTER NAME / he I Pere l la LICENSE# /Q(o JQ SIGNATURE
MP MGF JP 13 JGF' ( LPGI U. CORPORATION_1#' I PARTNERSHIP L# LLC #r- I
COMPANY NAME:_/f e j--e j 4 j (fl 74 t ADDRESS OZ T 1,c0A)i c nCc. Li) • I
CITY •e/�f�erv/ZLe I STATE /2 IZIPeJaZ . TEL\ De' 'f?O'pZcU 'c I
FAX _ _ __ __.- - __ _ ___.._ _ .--- _ _
CE 7 6 EMAIL
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