HomeMy WebLinkAboutBLDG-17-003322 'I b0 I6330)o TA
4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FI TING WORK
1v+i. _ -
`a CITY MA DATE' fa PERMIT#
JOBSITE ADDRESS OWNER'S NAME I
GOWNER ADDRESS 1 TEL} 1FAXE
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1 RESIDENTIAL
PRINT
CLEARLY NEw:EjRENOVATION:X REPLACEMENT:. PLANS SUBMITTED: YES 0 NOX
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ..
BOOSTER L. -�. w� aF�_ �,� v. F i_. JI
1 JL, 11---_-
CONVERSION BURNER _...
COOK STOVE , I
DIRECT VENT HEATER --o-
�Ji1„ ;.. L 731 t ,< .J call jir. , .{
DRYER ? A �. i. I_ '
FIREPLACE _ _ _ _
FRYOLATOR 1: —_,JE.�,,..s 1 —_,1 -... .. . , .,f ,. 1 . i _.„„lf_ l,fic,,maa ,.F�.:: ww' .�...
FURNACE _
GENERATOR _. _, ;_ _. ,�.. .._ , _ ..�:
A
GRILLE k J J � -1 "! l '_ 4
INFRARED HEATER `. i
LABORATORY COCKS ii
MAKEUP AIR UNIT . � '� �d— 1` . .� � 'Tr— _.. —1 ,—w. 1� t ....
OVEN " f � j�i `J 3 1 :.
POOL HEATER
ROOM/SPACE HEATER - A , I
ROOF TOP UNIT 3 I 1 �� i
TEST ..-
UNIT HEATER „ Ir
UNVENTED ROOM HEATER 1 r ij _. k„,
WATER HEATER _ � .�. �. ' --i -a' _.,.. '
OTHER _ I _.c .. i_ , _ .., 11. .a ,
i, i i I �C t�
} ,- ,a...awrn uxx.«.cm s � ,.. ...,.......:: 3 L -� 3. i<m.w.,z+. k .. iE
,. .... ._ ... �µ:fl.., .,,,.__..t S .._J x ....ff.z 1 - I , I i a _3 .� „ _1.,,,,„.„,—,11,, 3r . : ,:an....m...v. ..,w«+,,.. .x.>.u,.a.,e �m:..««a�n-s.3 _ss..nmK .«�a«�
INSURANCE COVERAGE M
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES X NO 1 A
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ID BOND 0
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 0 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 corn r with all pertinent provision o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
tr
PLUMBER-GASFITTER NAME r l 1 LICENSE# 15 a(J SIGNATURE
MP A MGF 0 JP LI JGF LI LPGI LJ CORPORATION # PARTNERSHIP # LLC l#
COMPANY NAME: ADDRESS 3 _ _ ,
-
CITY __ _ f STATE I J ZIP . p TEL a �( . . :
FAX 10ELL .,_.__._.,_,,., EMAIL .H.. : .,-N. .�
0-
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