HomeMy WebLinkAboutBLDG-19-005665 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
wl_!= CITY uV G1 r`(yl C9.C)'-- 1 MA_ DATE PERMIT#,, �)9"PG/6
JOBSITE ADDRESS'_.
DDRESS'-3? (o/) 5 np.^c_MA_.
NAME 74iiZM (.
OWNER ADDRESS Gt.�/ j TEL _ FAX` }
TYPE OR OCCUPANCY TYPE COMMERCIAL;] EDUCATIONAL J RESIDENTIAL :.
PRINT
CLEARLY NEW:3 RENOVATION:}(,( REPLACEMENT:—i PLANS SUBMITTED: YES_1. NO f
APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER __I______I______I. I__ ___I I—J i—J___( F— ___-_1—1
BOOSTER I I: I F __I____IJ— — — —— J. 1 I I
CONVERSION BURNER I I _ I I 1 I. !_J: 1 I'__I I__1
COOK STOVE I I ':'
DIRECT VENT HEATER I I._J__I;____I I_J —1 —1' J I __I__I
DRYER' _J_—_ -1�..-_____I
- ice-
FIREPLACE I I 1 —.I 1_-I_-__-1 I s-. I I 1__I_J I
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FRYOLATOR I —1-1.J. I I i __I _ I J�
FURNACE __I —J I I _ I _1—1 '- '-__I_ I I
I GENERATOR t_____I.. . I.... -! I ..-. � ;- I I I I_
_GRILLE _.i - i__I -_i I1___3__.__I I ._1 ___i.____1I..___I
INFRARED HEATER —1__I__II J _ J i.� ___I__I_1 I.
' LABORATORY COCKS I { I I-__._J I !____J. r.__i____1 �s _-1___I-___-__I
itMAKEUP AIR UNIT I I I I I i I I I i I 1.
OVEN 1 I I 1: I I 1 I i i I I I i
ab POOL HEATER _J�J I I. I 1 _I I�J 4 I..__.._)._1
ROOM/SPACE HEATER I I q �I =.. 1 I ____1 •_�• I. ! - I _ I I 1
ROOF TOP UNITI I t ' I 1 I 1 1
TEST O U7-S r. 5e./v,t__-__:__i_.,,LI I I_._._i __I_____._.i I_ _ r I" I I
UNIT HEATER G ` , .- i I _1_I 1_______I. I_!
UNVENTED ROOM HEATER �� _1 [ _ �, ___-___1 __1_J.___.I I____� I_J
WATER HEATER - -_--------- - I i . : I I I ' ,.J.—._...I I I I I I
OTHER '. I I I I.. I. I I I I-_-_J 1 1 I 1 1
► • I I 1 1 I I..-; I_..___1 . .. I ' _t . - I _J _ .I
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t I I I_.___1--- ' - _- -` !___I _=-I___J __
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INSURANCE COVERAGE _
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 111 NO 'J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY . OTHER TYPE INDEMNITY ILE 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 ,__I AGENT _1
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. �� -,2C 2
PLUMBER-GASFITTER NAME i "1 t N c- +r , c. F I LICENSE#1 y(F/_ n SIGNATURE
MP ___I MGF J JP JGF;J LPGI J, CORPORATION(_I#' I PARTNERSHIP=L# LLC:_(#
COMPANY NAME:' MIk/t C_ r i c Qp 0 f 'L/- ADDRESS C (J- (/,5; (� 4. (`f tj--e
CITY -- - ._ .... . - .'M1 M `J - --p-. -._.. f. STAT�rv"�—` ZIP __ �_^..—_ -- -. _
��� "� �'? `21Q 731 TEL 17 y -T O 91l I.
FAX 1 CELL: EMAIL -t n t/` M c— r_ cQ.n .( .. J "1-
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
77- / ( (,
PLAN REVIEW NOTES
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