HomeMy WebLinkAboutBLDG-24-550 757 a�
g ,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r'---(„.__,% CITY Gi v h?-ti Th._—- . ! MA DATE' (PERMIT# �L D 6 2-'7- 55
JOBSITE ADDRESS O" tgoJe.2C [OWNER'S NAME �o rdG H C4//�. I
G a_f .S
r � aC ,_3aRtQ _____ __- �_
OWNER ADDRESS i !TEL FAX- 1
RTYPII�T OCCUPANCY TYPE COMMERCIAL;' EDUCATIONAL _._-_1 RESIDENTIAL',J;
CLEARLY NEW:J RENOVATION:J REPLACEMENT: si PLANS SUBMITTED: YES 0 NO
APPLIANCES 7 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _ ___,_1 t (___I__J i1_J_—_I___( t t_J—1
BOOSTER I-J I. ( i—)—1'—U U_J.I—J_J__.1 J
CONVERSION BURNER I_I_!—I_J I—J—_—_I __I_.1'—.J! ._I-_ J
COOK STOVE I I,! ____1,— —�——11 : _I — _I_____:.1! . i
DIRECT VENT HEATER :-1
DRYER• 1____.1—1-1--I i-__—!'-J-- .1 I I—1—__I I
FIREPLACE I_J—1_I_1_j_1.1 i____.1I— —I I—1 I
FRYOLATOR I r I.,-- I . I I.- -.-t__ _I ________f I ______1 __II____.1-1
FURNACE _J—1-_ 1. i_-1"J__1 1___I_I 1__i`_J`�I I
1 GENERATOR I I.._ i . . . !_.J I_�_J- I I_.1_1 GRILLE GY%J�/e. I .. I I. . . 1---�_1_____I 1 1 i __I_I_1_-J
INFRARED HEATER I $--1._J I_1_-1'_1 `—J _1_____I_I_-1
LABORATORY COCKS I - _ 1. 1_1
—J-J I . l_��.J____1____.1
� _I_J
it MAKEUP AIR UNIT __ ` ... -. I .__ 1__1 1__ i_—J____1 _J �._1,__._1._1
OVEN I I i--I—I-_1, f _J I __1—1__I__J 1
POOL HEATER I_J,__.__I !,;Li.r I._ __ J=1 J_____I- __.j I-1_J
ROOM/SPACE HEATER I r___1 . I_J _.__1____1 i I-I I �-.. '
ROOF TOP UNIT I, I I I ? ! I__I,__1` - -C-�J�1�__.ji 1
TEST i i I i I 1_I.____J__+ _-.I. ......f.__.-_1.--- I
UNIT HEATER i_J___1 ( I __
i 1 ___ - - i I .
UNVENTED ROOM HEATER 1 1 _ i f ___.i—J �17� 1 ' 1[12 i i (
WATER HEATER
OTHER ,1 I i. _1__ 1. ._I
i 1 1�_J cCCdr=A;i1 4Er7111
_�- J ;_1 _ 1 I 1_ 1 1 L( 1
• I I-_1_ K_I UI I_1._Li---J UI I -I_ I J__-,._:,-.1-
1 1 . , 1 I 1. I I I 1 I. I I 1_ iI
t INSURANCE COVERAGE _
E. I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ij'"NO 1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY kf OTHER TYPE INDEMNITY BOND Li
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ;- i AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME n�S rY1 . (rn�� �� d 9h s�'
Y-I LICENSE#' �$C�{� SIGNA E
MP t MGF U JP 3 JGF A LPG' J CORPORATION'_(#` -2' ' f PARTNERSHIP!# 1 LLC _(#`- - f
COMPANY NAME:'-
AME Lf-CC PO‘n P 4K , L I ADDRESS I t 6-ON Q -5-7-
I
CITY tij tzbe,m6 0-tr., I STATE}141 I ZIP O o`Z 6 J) i TEL '71 44-- s3- '6 rj - I
FAX I CELL I EMAIL 61)-- p,>1 6-�1 ( Gil e� I