HomeMy WebLinkAboutBLDG-20-006419 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS t 3 rr/)J p_r iY C.t I OWNER'S alE6 �1 rI(�/j Dr/ i
GOWNER ADDRESS ci 5 S �A��` J/..�� I .__ — 1.
TYPE OR OCCUPANCY TYPE COMMERCIAL;] EDUCATIONAL _J RESIDENTIAL
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CLEARLY NEW:J RENOVATION:J REPLACEMENT:K PLANS SUBMITTED: YESS.. NO_[
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —J ___1_I—_1 I___I I I—J______1__J__I____I—J
BOOSTER 1 I I t 1_! _ I_1 ____I I__1__I_1
CONVERSION BURNER i _ I I I I 1 I _J _____1 I_1_I
COOK STOVE ( I . 1 I f= !—J __.. I I. I I I I t
I ___I __I
DIRECT VENT HEATER I� .-1 f� ' —J_� I I ! i
DRYER• _I_1 1 _1____1
I �1 I I� I I
FIREPLACE I I J I__J ; _..__I 1_I�� I ... i 1 J I
FRYOLATOR , I I I
J1--1 - I i - I I —I _ 1
FURNACE ____I I 1 I_ I I_._____1 _ I_ _i _____I __. .1 _I I
I GENERATOR U lJ T� /oe ill . i- e i _ __! I 11_ I —I , ;
GRILLE —__i 1_1—_I 1 ____I _._. I______I ____.1_______I i __-J ._._J .I.�.J
INFRARED HEATER _ J _�_ _�_ , ..._ 1 ! I ! _J__I I __,!
LABORATORY COCKS 1 l.,_ _!._.__1 ? I _I .__f__ i__I_ I
MAKEUP AIR UNIT —I I J . __
1 i j _! 1_ I . ! 1
OVEN ! ! I ''_—I_____I J ____i ____,! ... i i I__.I ____!
POOL HEATER I __I__.. ' I J_._.J; 1 __.__.J____...J I
ROOM/SPACE HEATER
ROOF TOP UNIT �____ .__1 . � __._._.., __.._._J_ ! �Y' � ' _._ _? _.,_.i _..._.1
TEST _ E_ __J__ ._I_ I ___I I
UNIT HEATER _' i , _ _._ I I i ? _ .._...1 - i
UNVENTED ROOM HEATER .....- _._J ? ___._. _ ___.J _._1 _ _J____i I_.____I _.._i _...___I
WATER HEATER _ 1 e!1 ,_. ' I 1 —_' ! I 1._ I 1 M 1.OTHER _ / f �° ! 1 I 1 _ i I i __I I I l .J_J
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to 1 I 1 I ; !~ 1 1 I _1 I I I 1.
INSURANCE COVERAGE
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ‘24
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY K OTHER TYPE INDEMNITY ._J BOND I_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.
CHECK ONE ONLY: OWNER I 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 C pter 142 of the General Laws. l) ri L. -- __.
PLUMBER-GASFITTER NAME 6C q e L ` 1 r LICENSE#leo,/ SIGNATURE
MP _J MGF JP GF—I; LPG' CORPORATION __I# PARTNERSHIP Li# C LLC J#
COMPANY NAME:. (f l / P.. [" 04__ 'ADDRESS ? 1Z U 3T1( 10
CITY 1 r M d ,.J(4\ _ - _J STATE 11/4I ZIP O Z tY 7) ;TEL 77 y $-6 l/ Z-�
FAX j CELL !EMAIL n e/'' C_ f 1 6 lj t!1,+9-I4- co
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
!JlG OA_ ?hiuu rb Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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