HomeMy WebLinkAboutBLDG-19-003795 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 6 3 CD.;s �ah C e ,Q�d' --I OWNER'S NAME :`7ry]Ae' c ��; O�
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OWNER ADDRESS 6 3j. 6p j hc. AA, �_„_� -1 TEL4 o '-2/-/6,o FAX- _-1
TYPE OR OCCUPANCY TYPE COMMERCIAL;] EDUCATIONAL _J RESIDENTIAL
PRINT
CLEARLY NEW:_ RENOVATION:-U REPLACEMENT:_I PLANS SUBMITTED: YES,_ . NO_[
APPLIANCES 7 FLOORS—. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BOILER _J i: I__-J_ I I I_I__I__J t__I_____IBOOSTER !. I I I'____I —_I__:__I I_. II I— —J
CONVERSION BURNER i I l I 1 I - I:_____I.
COOK STOVE - I I.i
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DIRECT VENT HEATER _1 I_—I—I 1 _____I-_ _I_I I__I_ _ 1
DRYER• ._I _. l # I - 1 1 ._. I� I I
FIREPLACE I I t I_J 1 I ; 1�.j I _ --I_j I I
FRYOLATOR --- r_ ( I 1:
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J FURNACE _�- I L 1--I—J `- I '_ ---'___1 .-- I i
I GENERATOR l (. . i. . i ( ! I ! ? 1—
GRILLE t (, ( _ __.I ' — __J '. I __ ._J I
(LABORATORY CO KS �J—J'�.-1 i —;_____!.______II - i_I ! ( _—!
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MAKEUP AIR UNIT `�_,U ! _ _.____J ,___I I I _I I I,
OVEN ' I I i ( I I I I I _ I —I ( (
POOL HEATER —_( 1_J_ , _ I _ I�_..I I I__J______ I. I I I
ROOM/SPACE HEATER ��, !_�I I 1 _; I.: i I
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ROOF TOP UNIT ! I__ 1 $ -. 1 i.- I S
TEST _/ 1 I , I f
UNIT HEATER I 1 I ___J - I_____I ______J"—__t__r -_._.__J '—_I
UNVENTED ROOM HEATER ___._I _1 1 _ I _____.1`_____.1 ._�
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WATER HEATER ------ --__ _ I- 1. . ._ i I - 1_ '. _1 .. . ` I 1 I ; i
OTHER -- I—.i � 1 _,I,__!.. I I I _ I_ I 1 1 I
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t INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES — NO . 'I.
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY .� BOND U_i
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 T- 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.
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PLUMBER-GASFITTER NAMEi1 �-'\ E ( �� 1 LICENSE# > .5` SIGNATURE,MP __IMGF'U JP , JGF' I LPG( U CORPORATION (#' (PARTNERSHIP # LLC:j# 1.
COMPANY NAME:; "+ :.--) t'` Ct.. L \ 1 ADDRESS - (c-.P tit,ri I, j Li,II-F /-1-1� I
CITY ,.% 1.- LIL r V I STATE'r' ZIP 7 "-CI.-CL1 ;TEL n ' �['f<> 4'l •.-
FAX 1 CELL. {EMAIL' /-40s,cr\(f-(ji.1 (lLc lisc;r.)_ I_C > '
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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 U 0
"a71 )// FEE: $ PERMIT#
PLAN REVIEW NOTES
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