HomeMy WebLinkAboutBLDG-17-001177 •
LG9 ; DCALCe ' : _ .
_-lit' • MASSACHUSET T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
*�: -e t'' CITY \k:Ac- (\[ 1 MA DATE 12,5 I(p 1 PERMIT#/ b c//7"7
110) . ..JOBSITEADDRESSI -3-5L ?,,ce' seek OOWNER'S NAME ON__x c Ae.- 1
GOWNER ADDRESS I' t TEL ^_ _%FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL)) 1 EDUCATIONAL {11RESIDENTIAL2
CLEARLY NEW: RENOVATION:Lj REPLACEMENT:l PLANS SUBMITTED: YES{1 NO
APPLIANCES 1 FLOORS- BSM 1 2 - 3 4 5 6 7 8 9 10 11. 12 13 14
BOILER . 1 =L 3JI. 'I__ Ai -1 _11- z'--1_ 1__-_=1 'L_ _
BOOSTER -l __- AI -- I - jI - '- -`I- -- 1 - I L_ _ 1 1 - 'I-- II ., _ f
____; (°
CONVERSION BURNER • I I ___ -I_ ,,I -- `L'I- - `I- - I - -- 'I .I - '1 - ___;1°1 - -- ` -
COOK STOVE I 11 I `I- - =I! _ 3; li =i IL__ =1 = -
DIRECT VENT HEATER I i Id—iil fl l [ 4 =1. II - al =1 n
DRYER_ II ill ILril 01 t1-1,1 It -t 1 11 i li ., - (Q
FaREPLACE I. al -- - -'I Y- 01 � _._-1 *i---- -= l
FRYOLATOR I I _ t l - _. tl __. L_I --- I .1 -` --- _a _ . .._1 L _31
FURNACE I_ RI.4l tl_ -- I _ I II _ - L - j II - _ i. t =1 .�:;GENERATOR j _l 1 1 __,[ 11 1 __ s �� 1
GRILLE 1. I. ._-'!I `I I __.-. 1I . al _ ( .. 'I =1 i 11MM
INFRARED HEATER I a I I I t jl—, I i .— 1 = II_ 1 i n
LABORATORY COCKS L_ `I _ n _ .I -- -`I- _ . i - -- ILIII _. ._- I - A = - `l _ e
MAKEUP AIR UNIT �L !^'-_ LT.-J----"L_ ._
_ _ ...._ �I 3I !I____ -1.{ 11 II UI - 1
OVEN ' '1 - L--- ___._..11 -1- - 'I -- (-- - ` -1�� `L-___j
POOL HEATER Si- -- I.___.__= _ :.._-- -L_ -- ----__. r
ROOM I SPACE HEATER L---.i_ __.4_.__ I_ _EI_..--I -_ --I--- - ILL_. .'I_:-_ _ .. . _.__ - ___1 .--___'L__...:
ROOFTOP UNIT L n01 -. 1I. --'1 -- t1 - `1 1 - ._ -tL I -- •L --
UNIT HEATER (-- _
TEST L- L-- =l L_ I 1 L _ 1 __ 4 •---
a� 3 3 �Pr-- • ' I it 5' I
UNVENTED ROOM HEATER -I i1_1 l j al = 1=1 -1! 4 WATER HEATER 1 �L ;1 _ _ I . III- � .-_._1 1"
OTHER
i "l-_-- it—_ -_L _51 _ _i___ L II ;I _, .I II____
L it -I —
- I - -I---. . =1 =�I — 'I --'I L- 'I, e_
_ ___ i1-
- INSURANCE COVERAGE 0
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 1 J BOND 1 U 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 Q AGENT Q
SIGNATURE OF OWNER OR AGENT
. !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 • t pro ' the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ %%� _____.,
• PLUMBER-GASFITTER NAME I C_ c, r I 5 , R i e.d e I 1 1 LICENSE#1-"y6,i SfGGIATURE
MP 0 MGF Q JP f j JGF-I LPGI L CORPORATION I '# 1 PARTNERSHIP t#j 1 LLC Ed
COMPANY NAMEi C c.,I-- I I . ICit?I d e l l t Son [ADDRESS i -7-7 Ii o, n S t re ek- _
CITY O S t e r-V i I I,e I STATE MA ZIP O '3.Co 5 5 1TEL 5 o S - yak Lp 3 Co 5 1
FAX CELL IEMAIL i
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44.