HomeMy WebLinkAboutBLDG-20-001234 c TMin2r9g-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_ CITY W C 5T `7' c ^M u F [ MA DATE 'V ( cf [PERMIT#e O1r20-0672 1'
JOBSITE ADDRESS S.� t37ci 0P v r o �'/ 1 OWNER'S NAME 1p 4!'/ III! LL S I-
GOWNER ADDRESS J TEL 1-7 `3--I 2y) gAx
TYPE OR OCCUPANCY TYPE COMMERCIAL;) EDUCATIONAL J RESIDENTIAL F-
PRINT
CLEARLY NEW:J RENOVATION:'.......1 REPLACEMENT:„I TE'5 r PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-~ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i__i—J-J--
' I I I I1 1 J . 1_1J
BOOSTER I l 1 I ! I . ._ _.— �
I I t __I___1
CONVERSION BURNER I I_ 1 1 I- 1; I _1�_ 1: f_ _J___iI j
COOK STOVE I 1 - I`—J __I I—1:� _1— ___1i J i_J _1 1
_
DIRECT VENT HEATER . I } 1 _1 I.._ 1;_1 I 1_ �;.
DRYER• I L I, I - I. _. . 1 .- - l.__1-
_. ... I _.. I. ...... .I . .. ....I -- I
FIREPLACE _ _I ._ I _.._. 1, 1 S I-_ I I I__I 1 i
FRYOLATOR ! I I.—s______I _... _I . r. I _1_1 _I�_ I
J FURNACE ____1I I I I ` I1_ I____1 ;____I-
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I GENERATOR _ . 1 _ i I ) .. .__ 1 ; I i I ! I
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GRILLE - i 1 1 ; ... _ 1 _J -1 ; ! J -� _ _I -J
INFRARED HEATER -J __I.-1 ! __
; ._ i J___I -J !
LABORATORY COCKS 1 1 1 `•._-VI I !,J_..__I___._I____I_ _j I_J-______I
it MAKEUP AIR UNIT
I_ ' I I__S -J_ I 1 4 ,
OVEN - 1 I I. I_ I .1 I ___I ___1 i - I___.1 I
POOL HEATER 1 I -_..J_.__J I I___J_____ .__.�._.I__.J;.r�i_. I.Y I__I__I
I_, I i L. 1-- I. I I 1 i _ 1_ 1
ROOM/SPACE HEATER i _ _I r W
ROOF TOP UNIT _I I I_�J_,_' I______J •___1_ITEST _ i I—2�I _I I _._ s I_ _ I___ I
UNIT HEATER _I l t__,J - I . ___J ___Ji_ : I J
_ _UNVENTED ROOM HEATER J_1.. 1 ,� I ,_.,._._•j _J 1 i,__I__J ___ i I
WATER HEATER ._-__-- -.--..._ I 1 ! I i?._.____I I. 1 I 1
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OTHER ` 1 I 1 I_ I I I I i.___._I-J. I 1 I I
p I 1 1 I _J i—i-+I,. 1_ I______I -I I'_--I _1_-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 LC(NO 1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY J BOND U_s
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
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: i� 1 L tiu4J4_ fq �i r ,. ,�I LICENSE#/ 7/7'i; SIGNATURE
_ �_..._.
MP J MGF___I JP;J JGF' L LPG' J. CORPORATION :1# :fir C`- � [PARTNERSHIP # LLC J#: [`
COMPANY NAME:' ;A(
V�A 3 _'1 c " r - 'A.l f ADDRESS 61 —12 C:J+ S'77 C e 1 V _
CITY \&J / ,Ai,-
d Li l_ , ST ?Z`� /D / Z
FAX I CELL: .. !EMAIL! <-1. n iJ.C/' .7../N.-,r '-,! s ct j !rL 4 /t, C U 11 -‘ -1
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1937 Leg
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ROUGII GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# fii'�% fw
PLAN REVIEW NOTES / t-/
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