HomeMy WebLinkAboutBLDG-24-549 SD. O
�. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
2•P":`" CITY : --ref,/4O t!/7? 1 MA DATE` I PERMIT#1 L O G-i`1 -511`I
JOBSITE ADDRESS` • 1, '.- T OWNER'S NAME D /r� O,S e ifI
GOWNER ADDRESS ; = �. _-_ .._.-�J TELA / .FAX f
TYPE OR OCCUPANCY TYPE COMMERCIAL;,. EDUCATIONAL D. RESIDENTIAL'e''
CLEARLY NEW: RENOVATION: REPLACEMENT: I PLANS SUBMITTED: YES D NO iLJ
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I {____1 G__._J.____4_I L._____1_J_J_I I,_.-_J_1.__I
BOOSTER : I.-J 1; I t`___j J3'-j-J .-t_I f-J
CONVERSION BURNER .I.__:__t______I__I -
COOK STOVE :—J_-.1,._t�1,:____I-t �:-_.—IL]._-J-1__J... J-J
DIRECT VENT HEATER I_} 1__I_- __�_J.__,1 t _�.-J_�:-J
DRYER• 1_JJ._i•-_.)_____t: .. . .l_J—_1�: . .. I - .I .I.-_-!-I
FIREPLACE .- -I.- _.....I_.J _J _._._I..-.i:. .__II,`_J. _.. I ___ . _1.___J_J
FRYOLATOR 1. ---12::::1-- - - .:.I:____1--_I -_I-J._I _-1_�_-I_____ =
FURNACE I.__J--J._J_ --j__:_____i __-___.___I- -J'______i_._I____J�. 1_1
IGENERATOR q1.. .. . I t._J 1 I______I .__J___I __J_____J.___!—_1
GRILLE I - (.__-_-___Li_J.___.....1I:,__L�_!'_�____.I_.1._.._.J:.__.I_:____..1._.�J
INFRARED HEATER - I_J__I.—J I'_ I.^J:_1 _J —J.—�'____1-1_�
LABORATORY COCKS I_3._..__t__-____IL_Li - "1 !_ LI .I__ I L_._..] ,J____._1
itMAKEUP AIR UNIT t:, _ I _—J_.J_J.�1___.1___J I 1__I__I__-_-3:____.1
OVEN -- I._..�I l _I:-i'__.I_.. J I _ I. ! ____I_.._1._._ i_.___J I
POOL HEATER _J___..J I____I,__,_I I I,___J__I____a_I_-1._-J____1____i
ROOM 1 SPACE HEATER : _ I I_ - I I_J____J_____J_____I. ....I._____1 ___.._._ 1__-__Li
ROOF TOP UNIT -_._._I r __ I 1 ! i--I__..j, 1__,,_ I . 1 I. . !_—I
TEST ---__I_.._I I ?_1 1___.__J ! E IC r r--I c
UNIT HEATER I _I.._-_.j __! .1_.__J ._.1-_rI,— 1-_ .. !-_I
UNVENTED ROOM HEATER _._J _1 •! I _ ! I _ I,_,.,__._i l I__I I_4.,-j_,__I
WATER HEATER -___.J�'.___J_.___1 1__._J_____I__I _.1 �1P
OTHER ___I I..,.._____I _J T:_!_J_J_.t 1___.._..I__..-_I ...i...._►
_' P �W . _�,_ i___I _ w. { I.__.1___J 1__...:J'__.___I. ,.may.- , >A FtvJ:-+-�-I
1.�_._J._._.:.I. ______:1 1 ►---J �__J . t: y_J-�J
1 ---1_.1 I.�__ I _... ! I _ I..__J i I__I _J _1 I
t INSURANCE COVERAGE _
tI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES If' NO .J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .h OTHER TYPE INDEMNITY ,.,,_1 BOND (J
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 7 l 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. /J 9,
PLUMBER-GASFITTER NAME; n S t m & (\Q. I LICENSE it,6)go K{ SIGNA g'E
MPIGI'MGF J JP JGF',A LPGI J CORPORATION'S#'.,5 f PARTNERSHIP.!.ti LLC:_,(# - t
COMPANY NAME: 1�}( L (�a t n s Q K L I ADDRESS ]t & pv�P -� I
CITY totaie.frv3 I. STATE MA- I ZIP D 1 b 5) TEL' '�7�- ara b. 6 r1 I
FAX CELL. I EMAIL: &6-&-t, b M G--S k C,,0. Yea Lv r