HomeMy WebLinkAboutBLDG-17-002896 ((1 J 1 00 Vt1(,1! /a 0 .
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_"' CITYd> / J-E \ I MA DATE [l—I /6 1 PERMIT# .4Df '/700 %
JOBSITE ADDRESS 30 Pv it,h 6-- /i (OWNER'S NAME k/Ph
GOWNER ADDRESS TEL> ' S'y? � � FAX-_
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL FA RESIDENTIAL
PRINT
CLEARLY NEW:D RENOVATION:® REPLACEMENT:0 PLANS SUBMITTED: YES Q NO❑
APPLIANCES 1 FLOORS-► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER =J L_—J,J J J J J.J—1 J—J;—J—_1
BOOSTER 1—J I J_J; - I L-1L _r_____I i —f I' —_J
CONVERSION BURNER L_ _J L __' I.' I_t!____I_J i_f__I i__
COOK STOVE '_J 1_J=—J!i—J—1 J__ —1 I—_J 1 I_____J
. DIRECT VENT HEATER L _�_I' 1, l; L 1, I f i' 7—I: E P E_y;.
' DRYER mJ J f�J°—J P—!'—fJ: ___J _ _—J
FIREPLACE 1 I f V I' _J 1 J—J_J 1
FRYOLATOR i I L_ _____I: `_I'_____ I L p I_ 1
FURNACE k• I 1- II I I I I 1
GENERATOR _1'_J_J __� - __I _._ —f^-J _HI
GRILLE J J'_ I•,_ ,J J i —J I—1—I—JII
INFRARED HEATER _I JJ`—r _ —J— ~ I' _ I J'__J_-'
LABORATORY COCKS .-f ---___LT-
_ _ L—J——J� —J— _ I—J'J—J J L____II
MAKEUP AIR UNIT i _J ___J__f:J F^J 1 __J—J J__ `—..J _=_Il
OVEN —1! —1 I.—F--J._==J_—r—J J--J—1 J__II
POOL HEATER •J_—I!_Ji—J— ___ I_—I"J__J.—J __I_I J��_�-'a
ROOM/SPACE HEATER __J f_ _j_•_J I__1 -(_J._J'J:J_.J",_J°'_. 4
ROOF TOP UNIT f I_J' J GJ i _ JJ—J J —J f----
TEST '__f__J' L__J J J_J___ J I J—
UNIT HEATER i—J__J L__J !rJ'J J—1—J'-1<_J___1' i= )
UNVENTED ROOM HEATER -_k__J L_J°_1_J!___J__f ) I 'J__.1 ►____1"
WATER HEATER I=_—J t_J_J_-1 i • fa I_1'J— :__I _f:-_—J---�
OTHER L. _ ______I! I I—Jy—I—I—J' 1 I' .J J-
i J I I' II P! II I: f r _,_J
_lJ_J —rJ! J J1J iJ I;-_f_
I J! -Ii • r I _J JLJ__J I —
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 [l
I iF YOU CHECKED YES,PLEASE INDICATE THE TYPE Or COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY D. BOND 0
OWNERS INSURANCE WAVER: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 Ej AGENT D.
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 actuate to the best of m� owledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia c • 'all Pe 'of the
Massachusetts State Plumbing Code endd Chhappter 142 of the General Laws. •
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PLUMBER-GASFITTER NAME / Ile/l LICENSE# _.? GNATURE
MP..12riviGF El J1 F D LPG!U CORPORATIOL.r#47,006 PARTNERSHIP # I LLC IJ#T-7
COMPANY NAME: Sd? e)(,t 15 ,—t) ( ( __-��ADDRESS -�7-
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CITY 0"\r/.P c:,v1 _S I STATEW ZIP IS&, " !TEL <('C"�SS7Q f C7 .
FAX® e CELL 1EMAILI i I
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