HomeMy WebLinkAboutBLDG-17-000343 MASSACHUSETTS UNIFOKM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
__ CITY J /fimJA MA DAIS ?A //c. ,PERMIT# //A19tr-17- J,'t1
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JOBSITE ADORES: �t��� r_ OWNER'S NAME /'
GOWNERADDRET5 /t f I , , ITF ? 1-F 6 -?3Vc ;FAXL. _
PPS R OCCUPANCY TYPE COMMERCIAL j EDUCATIONAL] RESIDENTIAL
CLEARLY NEW LI RENOVATION:0 REPLACEMENT_'- PLANS SUBMITTED: YES D NCI
APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14_
1 BOILER t n
BOOSTER 6� �. __ a
CONVERSION BURNER --lit SIM Miir l
COOK STOVE IIM Milli MI l __.
DIRECT VENT HEATER Wall irt • - -
DIRECT
ER .2 -_ .7:
IFIREPLACE WINK
_ _._.
FRYOLATOR Wall SIM - - __- _ --
I FURNACE
GENERATOR 11.11W11111 . _ . NM ME M- L _ -
GRILLEillir - M --
INFRARED HEATER - Mir= _ - MIMI - - _r°
LABORATORY COCKS NW- j2= _ M -
MAKEUP AIR UNIT N Ma a.--� r`__," .. _.. _
OVEN M _- -
POOL HEATER ,---r� � - - ---
f ROOM I SPACE HEATER Mt NM „n O II
ROOF TOP UNIT NM iffik UM MI Mr -_
TEST IM Mir Mir all - - -
UNIT HEATER -- - - -IL= ---
1 UNVENTE D ROOM HEATER - - .ilillt um - --
WATER HEATER
inn on . ._ NE—
ini
OTHER �' MI-_ 111111 . ___
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Ai.ini:ME wefts.
i III NW .- _ -_
_ INSURANCE COVERAGE
or its
I have a current liability insurance policy substantial equivalent which meets the requirements of MGL Ch.142 YESAI NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCYN OTHER TYPE INDEMNITY 71 BOND LI
OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
thaton this permit application waives this requirement
Massachusetts General L awsXand my signature
CHECK ONE ONLY: OWNER AGENT Li
SIGNATURE OF OWNER OR AGENT
I hereby certify that ail of the detais and information I have s&dxT ted or erased regarding this application are true and accurate to the best of my knowledge
1 and that all plumbing work and installations performed under the permit issued for this appccation will be in compliance frtinent provision of the
i Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME i M.14 Re 1_,t t<-}&/V I LICENSE# SIGNATURE
1
MP MGF JP J JGF j LPG CORPORATION/# 77e !PARTNERSHIP Li#i ; LLC J#
j COMPANY NAME:;_ } (kin�rn t't�Y.R/�if I ADD``RE`` sst g3 Lit-itch? A4J•
j CITY P1p}rn v Lil e_ i STATER , ZIP ,L)74 i (�- 'I! �
i FAX f-mC1 -zis CJ 1 CELL! - 1EMAILV G ; aailbin&)Gf-,n> /d J,i 1-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT M
FLAN REVIEW NOTE,