HomeMy WebLinkAboutBLDG-25-152 1Z. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-►_ _ CITY \ 7 r:M . MA DATE; _.. ._ . PERMIT#
JOB SITE ADDRESS I 7 I721 j/ 7,0/ � OWNER'S NAME l'r _ ,V 14U �7�/1 I
GOWNER ADDRESS ; TEL Z ,Z -�O 1' TFAX'
TYPE OR OCCUPANCY TYPE COMMERCIAL;,,_J EDUCATIONAL 23 RESIDENTIAL
PRINT
CLEARLY NEW,J RENOVATION:J REPLACEMENT:J I f PLANS SUBMITTED: YES jD NO (
APPLIANCES 7 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ___J_I_J I_____I____I_1;_J—J_1_1______IJ—}. J
BOOSTER -_--1_J'_____1: C_-C-1'J—__1 J J t 1 I._1
CONVERSION BURNER I_j_.I_f.1 t_ _ t.__j_J r—J�:__;_j____I
COOK STOVE __!_1 _Li_—J- -- '1_�—i__j—J____I .I Y_1
DIRECT VENT HEATER -_f-___rr— ., 1—J—J—J_L__1, _i_J—I.—J—LI , _..._ r
DRYER- —I�—! �;— —J.—lam—J —J;-�—1_J,-1
FIREPLACE ,_-]__ -_J _ 1_ — — — �-J— 1 t____1 J. ___- J;_J __J�J_1 j_ L -J I_____I
•
FRYOLATOR _J. �'� t.— JI J _ 1— _J.—J—�
J FURNACE _
GENERATOR I t r
GRILLE _ J ( —J 1 ... -I` _1'-J J-J-1:`-1_J—_1
INFRARED HEATER —J D-J I J_—J'_ J J_J i—J'_J _J
LABORATORY COCKS I . - I'__I_�1.-_J.-__:_-.1I . - t__J__-_J__.J_ I-_J,_,.1—_i
▪ MAKEUP AIR UNIT _-i f—J'-1LLD'_1_ ' C__ _ __Li _ _..
J .—_I I__I-J.__1
► OVEN -` .r_ -. F I__!•LJ_-J j1. I:_J_J ___J�LLD-_I_J 1
kp POOL HEATER
ROOM/SPACE HEATER - -I rJ,-J I___J_.J__J j__._,J." I_...i____1 J I I—J
ROOF TOP UNIT _I_ r__ t i__I__J—J' I___ _j_J..II.-J.__1
TEST '1 -fir —J / I I !L-1 1—J�_I,J I J f C - I r
UNIT HEATER —J . . 1 I J . . : i__I_-1.__,J I _-J.._j.
UNVENTED ROOM HEATER . __J—J .i__. j_. )__I I_ _J I_ J-J—j,_a'_ . j I
WATER HEATER _I t`.. . . i._1__J__J I___I_J_J,, -I 1_ l_J I
OTHER HEATER -...--A --- N 1__J. , . -t I_ J I I_-J__J-__J-_J. I_1 I, I I.
I__J t I-J_I_.]-I I_I�_J - J'_-1 _J-1
1 I_J LLD
___1_�J I• I_J--__I_J__I ,I t_I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY _ii BOND LJ
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 J
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 j.
and that all plumbing work and Installations performed under the permit issued for this application will be in compliance y4th all pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ` l \ i.
PLUMBER-GASFITTER NAME.: :'14P( Ikr I- � I LICENSE#it1 -' SIGNATURE
MP __1 MGF J JP J_JGF J LPGI .J, CORPORATION #' --- _ 1 PARTNERSHIP_!#' I LLC:.J#1 t
COMPANY A E --- '----- - --- .- -- --ADDRESS- 7 __..--_. _:07--
CITY 9'6 is I STATE I ZIP-ea1'(t/0( ITEL- 7 2 ' Tie w 2 I
FAX I CELL' - I EMAIL' - PI r
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT#
J'LAN REVIEW NOTES