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HomeMy WebLinkAboutBLDG-20-003177 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _!► e' CITY LJ q r1►1 D�� (; MA DATE PERMIT# /j�06-020�0 (77 JOBSITE ADDRESS/ e e (1st. g ro o4-k'•O I OWNER'S NAME 1 GOWNER ADDRESS ; (TEL _ - sI FAX' — — TYPE OR OCCUPANCY TYPE COMMERCIAL:) EDUCATIONAL J RESIDENTIAL PRINT CLEARLY NEW:.) RENOVATION:J REPLACEMENT: —I PLANS SUBMITTED: YES!) NO kr APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _I I I I I I I I_I __ _ I I 1 1_ _ BOOSTER I I i 1 1 I —J __ I ). I 1_1___1_I CONVERSION BURNER i I t I I I. I I I I 1— i I � I COOK STOVE I I I I 1_ I_J 1�—J—I I _I—J DIRECT VENT HEATER i I I.�. I ` _J _I I I I I DRYER' I i I I I_J l .I I .I J I I FIREPLACE I I I I I _._. I I _I I__ I 1_I_J I FRYOLATOR _ - .. -- I 1. 'I. I 1 I I _ _I _ __I I I 0 FURNACE --1 II I I I t-�I i , t IqIGENERATOR . I i__.. I .._. _._I i__J j i i GRILLE . I 1.__.__I J_._._J_____I l_.___i I _____! ._.__I J .____1 INFRARED HEATER LABORATORY COCKS -J I_..-. I I __..-i 1-_1 I____I !__I_____I _ ' I ___ . _ _ I ! _i I_! I. -1 i !_�I I_J itMAKEUP AIR UNIT '_ Ii I J_. J _i I _I i--I ___i _ f OVEN ! _ ! __ ----- I _ I I _I ____I_ I _.__I ;! ______J_.__ I POOL HEATER .--I _'_____I !L—_I____'____1__'_ _.._I_ _ .1.__..__,' _.1___.__1,_____J I ROOM/SPACE HEATER J t._ ! __—I I r._ J '_.. 1 ! -._ I _ .__.__.1 _..—I I ROOF TOP UNIT _..._...' I_ .__' I _o' __ _t .I �_I i I _�_j_ I . ' TEST __._i __J __; _ '__I—__ __I I UNIT HEATER _ ' _ _ ' UNVENTED ROOM HEATER 1 ______I_ _' ___._I - I_.__,.-j ____J ! I ___-_1 _._._i ___.__..1 WATER HEATER f __.__.I._._._.._I_.�.__.. I.._ I_ _I _.... _i I 1 I — , J OTHER I - 1___I i I__.__..L—_._I __—_l I __ I_. ! _! I' 1.__._.I__..__I • _ . — 1 _____I _ I______I _ I __I i______I'___I . _i �_ i �_,I I I I RI i i I l t i 1 I I I ___I _ i 1._ ` _--.-I ___..-_.i y___' I l ____.2 t INSURANCE COVERAGE ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES V NO I I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY J BOND 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 —I 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 ILY (A - �C [ L�/ C/ ICENSE#fW I r SIGNATURE MP _.1 MGF ,.,_J JP A JGF J J LPGI CORPORATION' 1# Y ...p _ . ('� � PARTNERSHIP._._._i -_ # I LLC �(# COMPANY NAME: rr i dij 0 ,� i ADDRESS (� �( l . .. .. ... . ik CITY 1 p I C( ('I� ©i/ , _I STATED ZIP 6Z07TEL 7l� g/e q/ 1. FAX CELL v/ EMAIL 5 r' -p --,n �r► ® IL s CD "-s i. ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT# PLAN REVIEW NOTES • \OSA. /kr-AA %IC C. •