HomeMy WebLinkAboutBLDG-20-000069 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
i r CITY - u{t MA DATE 7.`� ._ PERMIT# / 0
JOBSITE ADDRESS becl h I OWNER'S NAME r.Cth F-q yl Api2147 I PC I
GOWNER ADDRESS F r�J .. ._F ii_,. S h fee _ l TEL - FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL:] EDUCATIONAL J RESIDENTIA _
PRINT
CLEARLY NEW:J RENOVATION: REPLACEMENT: —I PLANS SUBMITTED: YES IJ NO_(
APPLIANCES 1 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 I J I__J.—__.1 I I____11—J___ I_—J—J_—j
BOOSTER I I I I ' _1—J —J —J 1.J____1___I —J I
CONVERSION BURNER I I I 1 I {. ! '
COOK STOVE I I I I I--I—i J:_1_1 J—1 I_I J
DIRECT VENT HEATER 1 _1 ._I J___1 ____1_I I__IJ I I_J _J I
DRYER- 1 1 { I—1 1 __1 I -J I I I I {
FIREPLACE I { 1 1 J I I I { J I I I--_I {
FRYOLATOR ? I I 1 I 1 I _ —
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GRILLE
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FURNACE __ ! 1 — -- -
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a 1 I ____1 1 J—_J___1 ___I___J I ____I .____I ._-__1
INFRARED HEATER { I_-J J i _.. I - I I J ___1i______1
LABORATORY COCKS ! !______ ._�_I i_,_I { ._..__!_._..__I__ 1 i_ 1 L . I_______IMAKEUP AIR UNIT - { J _ ! J I ;—J _ [
OVEN )1_ i I +. I I _I I
POOL HEATER _ ..._.._I_.._I_. __I .J>_—!_____I____._ _I_—..J__.-_--1— I.__-___1_ J i
ROOM/SPACE HEATER
ROOF TOP UNIT , .�.. �..', _--' , � { --- I,--� - - i _.�.'
TEST =r i f _Ji_��i i I.__l
UNIT HEATER - —
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UNVENTED ROOM HEATER I_ I ! _____1__ ,_.___i __ _I 1_1 {__J _._.__i _._._J
WATER HEATER J J.J 1�.._.J I l__ ._I _ I I I I
OTHER 1 I __! { I 1 J __ _i __J — ' i __ j
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t ��— INSURANCE COVERAGE ��� _- .___ ____ -,
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES.�J NO I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J OTHER TYPE INDEMNITY .J 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 _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 Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME, j ( ' • � 1 LICENSE#
Z(oi SIGNATURE
i
MP J MGF'J JP__. JGF J LPG' _J CORPORATION I# (PARTNERSHIP_I# I LLC J# _
COMPANY NAME yl� r&/Y2 I ADDRESS 210 cC/Jmiv
CITY _SD CM. yq h _..._ .�__._._
_...I STATE,IAA IZIP(72.f' 6q 1 TEL . -zJ4 -c_0-bre_
FAX
EMAIL- 4 SrnYl
1 CELL Q�1!r�^
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT [D
/
‘/ / FEE: $ _ PERMIT#
PLAN REVIEW NOTES
7h/7
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