HomeMy WebLinkAboutBLDP&G-20-006293 MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM GAS FITTING WORK
yq
1, -ro J, �MOLJI' A MA DATE PERMIT*/�l,� 'a0`l�Ol�et
�,��,L.�, CITY
tip JOBSITE ADDRESS 3 C4T (NAP 67-7: >L71V- NAME {J( q
'.',.�k OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:V- PLANS SUBMITTED: YES❑ NKV
APPLIANCES Tl FLOORS-4 BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER j
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE !
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN �1
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER _
UNVENTED ROOM HEATER
WATER HEATER _
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
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 ❑ 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.
`t
M (.
PLUMBER-GASFITTER NAME k � CL'eL A 1 r`cs9,0LICENSE# (?(00/ SIGNATURE
MP ❑ MGF❑ JP ix JGF❑ LPG'❑ CORPORATION❑#F PART ERSHIP� / ❑# LLC❑#
COMPANY NAME(\i‘ r i ADDRESS 9' (/ 5 c._-0
CITY "V r M, t/ STATE MA— ZIP 0 -5 TELD 7ti 7 /) Zc7
FAX CELL 7 y O (v 9, Z? EMAIL • r•
v
1
I
1 .
I
G2
cza-
0
.w
I CJ -
I ur,
I
1 0-1
i
1
I
I
I
1
i
>4 0E
i
o In
0 .
Iw1
w
I 4
6x1 =
L. - &I �. . >
' g .
Cm( U 4
W cn �C
P•
U
74
0-
I- i-
1 co
I C)
1 7
4
01
W
CCD
1 4 •
C
I C..
b
g
i
I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�.arc
=d CITYDa-L./ ��� [ MA DAT Zd Zv PERMIT#/2.+, MIRO-QGJ6+A?
JOBSITE ADDRESS 5 ('c',M i NER' AME ; ?p co c;
GOWNER ADDRESS S EL _•--0-7 6D 0 TFAX' I
TYPE OR OCCUPANCY TYPE COMMERCIAL;) EDUCATIONAL J RESIDENTIAL _J;
PRINT
CLEARLY NEW:;J RENOVATION:J REPLACEMENT: PLANS SUBMITTED: YES',_I NOkQ
APPLIANCES Z FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —J I__(_1___ -__.I I J I_.J_-J-__1_J-___J J
BOOSTER ? I 1 I _J_J 1_J—I. I I—I _
CONVERSION BURNER i__I i I I I I I ( I I ( 1
COOK STOVE —J .. I _ I 1 1. (-J—J ____I ! __ _S 1 ...1 I_IDIRECT VENT HEATER i I 1__. J '. ____1__.i - I--I I I 1
DRYER• I — ____I____I_____1_____1J ? -J __I I I I_ I I
FIREPLACE 1____I_ I_-1 1 I 1___1 I I I I I
FRYOLATOR _ r- s, __.-I I I _ 1 —J I J—I
J FURNACE _--I —J—J 1_ I _) I I 1—_-1 • ----' _ _i____I I
I GENERATOR I ' I I i
GRILLE ____a —_f.--! ____ ' �_1 ___J_ I _ i_.___I _ I ____!._._J 1 _.J
INFRARED HEATER --1 _-J__J _ J_—'_ .. . !- rl '_I _—J-�1 I __-!
1___ __.__I I I-_-_I I___.,
LABORATORY COCKS 1 I__ _ _____I I_ I ! '
jib MAKEUP AIR UNIT 1 —J ._.._I .J 1 ..__-I I ._I ._..Y�
44: OVEN _ I !.M! !_____3__ _.._I ! ___I _____I_____I _..___ -I i __i_______1 I I
POOL HEATER __I _ J.__ I 1 1 - J _I .J ____.J__J.___J_-_.J_ I
ROOM/SPACE HEATER
ROOF TOP UNIT ' _ I ' I '
TEST __I_._ t__ 1_ ____.I_____I 1 ____I 1
UNIT HEATER ___I —I 1 ---;___ _ '__ :1 - _' J -._ i—__.-..I ` _ .1
1
UNVENTED ROOM HEATER 1 , ___-WI i_.___.J ,___I _..._.+.1__._ri I_____J _.____i ___ _J
WATER HEATER /.1_ I.,__ J_- 1__..J ' _ _I ._._I_._ I 1_ I J 1 I
OTHER i 1 --' 1, I 1 '• 1 1 1 1 .1 1 I �._1 _I
• i. I 1 1 1 I 1 1 J _I ; I 1 I ! 1
1 I 1 I ` .1 ' ______I _ 1 _ I 1
INSURANCE COVERAGE
kI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ip NO _
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY r' OTHER TYPE INDEMNITY `jJ 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 ;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
pter 142 of the General Laws. \ J., Q11 ci.
I
PLUMBER-GASFITTER NAME NA \1i-Q � (...,,Z. (t cS_,}`LICENSE#/r a r SIGNATURE
MP J MGF'^J JP 34 JGF i'' LPGI RPORATION,�i#';`'�� PARTNERSHIP_1#— LLC I#
COMPANY NAME DDRESS f / 5`f 7 �J(',,
CITY 1J q i/'\ 6 c1 V 1l�( O7( STATE ZIP 0 l° 'TEL 1776 )7->
FAX i CELL' 1 EMAIL'+.0), � �3( c (�tc c-r,._}-/L- - C 0/�'\ Cif`
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT E1
FEE: $ PERMIT#
PLAN REVIEW NOTES
IttIA I • ig; t" •