HomeMy WebLinkAboutBLDG-19-003272 41 5-0
' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -1
CITY 411/111(4e/r/71 ' 1 MA DATE!/I tiariiir 1 PERMIT#,/ -4/36--/9".-6911
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JOBSITE A RESS Lt,,,,), --7. ER'S NiAME ,...
GOWNER ADDRESS
'TYPE OR
OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Li RESIDENTIAL>
PRINT
CLEARLY
NEW:1-1_,, RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES,7„_1 NO 71
APPLIANCES 1 FLOORS--* BSM 1 2 3 4 5 6 r 7 8 9 10 11 12 13 14
BOILER , .r;----7 ?, .,,
BOOSTER
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CONVERSION BURNER IT-72.717,..71-7:17r. .„ . 1.....„__JIT..---........T.,_IL ....::... ,.,,.. -;:r_fr..---jh'--- 17.---1::-.:71.7„.1-L72,i,
COOK STOVE _
DIRECT VENT HEATER . --1[....___!,,:-.._-_-W-:.:777417---71-----3- ---.j r---_-_,-71:: .._ :,f___.... .11_____:„
DRYER 1...,,,, -,,, F III !::..--::----;1?,---- -------Tri____ i_,,,1„_,,,,,
FIREPLACE I; ,, :I- ior- , ,.
„.......„.„-t.,..,,_........,.._„.. ,..„.„.........,_____-.-.,FRYOLATOR 1 111171,1_ -1,1::„_1[17.1-7____:' 7!: __-_,. ,e-d,.. _IT......
FURNACE ; __IL.,.... „_... ...)17. ......;a .. 7= .,... ..;.______J .,....,L ...., ,;', ____ _ .......
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GENERATOR 1-..- .:L.--...j -......•;,...,........3._.„...,;ii„,......_L„„„,..,...,?-1„____J',„„,,.-,.,.........„,1,,,.„
GRILLE1=.„...., : IL____..L......,.,,.,;',....._.„. 1,..... 4..,_r_„'„.........„....i......._,..,,i,„......_...i.L77
INFRARED HEATER JD. LT-7,...-...7.17:2E ,1 ---11____71.1,7.......a,..,_...:;,...........,. „...........;1.....„..„._i .,..,,....._:L.,.......,!,,...„...J1%.,.„...,....1
LABORATORY COCKS .1: 7 I _,..:[„1.......-71,---7- 1 ' g----7,1 •ii !, 1
MAKEUP AIR UNIT r!, ...-:1_ :.L,., .4.... it„... i; _
OVEN
_...--.....1 17,71...,.......-A—....--..,.jrn-jir::---::,-:,----21----jr----. 1,--------j1---4! '------J
POOL HEATER ,--
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ROOM I SPACE HEATER ,!' bc ", ,,
ROOF TOP UNIT .j,1_31.._____J __2i1_,:„1 ___=j_.............,... ....A_ ._.:4._,... l'
TEST '
UNIT HEATER ., ., .,_,I ;1
UNVENTED ROOM HEATER !: 1
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L...,„,:-..„,'
WATER HEATER
OTHER 1 ;1 4-----A---,--- ,, .:
L.,.....:-.. J -1---.7-----7, _._,....1„,,_.: .,...._. ._.,....,..L.----....,,J._
....,.--u.....s.....a^....grAra,---1....w.,.... .....-- - --..-..."7_7',
...f C„.......it __A 1„. . _ T. .'Ti .. . ;;.--.1................... .......,i',..______j
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; - ;!---:,-1:-.:t- , ,, 7.,____Th- 1----__,1:J1,-___---___JI:—1- . LL.I.:11._..._-,.;IL;3 r.-.------.' -_,I'-- 51,___ - --_i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ' ''!NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L:',„), OTHER TYPE INDEMNITY -1 BOND El
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 j= 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.
C'4‘) 0 C-1--------- ------7 PLUMBER-GASFITTER NAME LCraig Bish2p i LICENSE#1.15.101 j SIGNATURE
,,...........„.„..........„,...__............„
MP L7.---J MGFL„„„,:4 JP17.1 JGF L_ -' LPG!bi CORPORATION Lj#I i PARTNERSHIP D# 1 LLC Flit :1
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COMPANY NAME:Iih Efficiency ADDRESS1378 route 130 ,1
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CITY )Sandwich I STATE1, Ma I ZIPI02563 (TELL'
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FAX ii
;I CELL . JIEMAILiadmineni)h-efficiencyllc.corn _
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