HomeMy WebLinkAboutBLDP-18-004208 1
— t 96, rCC r
. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 1....``G,.�! (1� h ..a MA DATE k 7_Z 1 S 1 PERMIT#n P-iir=c'e
6,... ,G I,) JOBSITE ADDRESS[\LA, C-'UP G�c . OWNER'S NAME
OWNER ADDRESS v
TEL 1FAX 1
TYPE OR ialt
OCCUPANCY TYPE COMMERCIAL Lj EDUCATIONAL Li RESIDENTIAL A.
PRINT
CLEARLY NEW:jJ RENOVATION:LJ REPLACEMENT:50 PLANS SUBMITTED: YES D NO0
APPLIANCES 7 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER x
CONVERSION BURNER I—___ -II I.._.,_.._ I_. . fl.... __. _ 1-; m .
COOK STOVE I ,; 1_... =1 _._ '' I r1 _..
DIRECT VENT HEATER "
DRYER i _ ._ __ __._. ! ?} II __ _ _. !__ I _J._._....__- 1,_.____ }_....__J
FIREPLACE 1, �.... _ iI.:.,.. ..,1_--_. _, ...r_ ___-- _, .:. i _ _.___ __ :._ 1__ ,_ i____ ,..._
FRYOLATOR I I_..._ i. ! . 1.. ._.___. . (_,__,...41:_w._ _ _ 'l i
FURNACE I -II II } 41 II_._.. 1 .aa :' ._'! �.m=1u ' ._._ _.. vw. �4l ..,,...j
GENERATOR ___ _._f €.__n. _ ..,4I.. __ I�.__, . __,J,w _ r
GRILLE i I t, s
INFRARED HEATER i
'
LABORATORY COCKS _, __.__. _ __ ._1' , ._..._ , .__ ______ . n . I--„r._>. _�_. __.'_ _.,..2
MAKEUP AIR UNIT
OVEN I I il id ;I 11
}
POOL HEATER
ROOM/SPACE HEATER 1 1 .„. - __. 1— I i e
ROOF TOP UNIT I .__.... .L_ i ,,.. _( __IliII I _' I ,: __1_____:.1 ___ ,� _._ ! _ _ 1_____,[___ °-..,_ i
TEST .� .—.. _._._ -�
UNIT HEATER } ..,. _,. [ I._,.. _..:.. `1__..w. `i..__.. i1 ..,,: ..,
UNVENTED ROOM HEATER ' �' a
WATER HEATER II + i _. L. 1j,_, , il..., i i
OTHER I I : ..., 14 ;;I I I „ 3 i 'it 1_, 1,,_
I f{
t ' _ 9
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a 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 Li AGENT L.
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 complia ith all Pe 'aert provi 'nn a he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME C.c r,I S , R e cd e.I_L._-.,.,,....._y LICENSE# 6 S ATURE
MP 0 MGF® JP 0 JGF 0 LPGI 1.3 CORPORATION EJ# �rI PARTNERSHIP 71# LLC I #
COMPANY NAME: C c r I ___1=.Y__1-3,e dot!I..I.! ...Son_1 ADDRESS 7 7 5 IM c, i r-% S t r-e e .
CITY OSterv ; llC
STATE _M1 A ;ZIP _o a co._5 5 TEL 5 0 S- _........_�-1 a S- -_Cp 3(0_5_
FAX i CELLI_ _ EMAIL _._...
14.,Cf
r