HomeMy WebLinkAboutBLDG-19-001627 mMP: P4 RG ;c.-.'
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'a�__ 8 MA DATE '
E.�o�� CITY �' v. � � PERMIT# < ' .�� i A,
JOBSIT ADDRESS,$`_; _...L 'G. '' .v.v...-_.!OWNER'S AME L ' '�tL12
GOWNER ADDRESS ' t i-< - 1 TEIL ®77,i, 7 f,;j FAX
TYPEOTR OCCUPANCY TYPE COMMERCIAL[, EDUCATIONAL a - - RESIDENTIAL 1,., —
CLEARLY NEW:D RENOVATION:0 REPLACEMENT: _"„'"`.. ,-__ PLANS SUBMITTED: YESLJ NOD
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I( I I ! r
BOOSTER __. i- ' I -,--1
-----11-- 1--------_ LT. --r-- 1r-- ,CONVERSION BURNER 11 1 M1 I i )1 �.jr ; i �, i i i i 1, �,�..ate:::"
.1
COOK STOVE I mo,_:1 -. i , 1 .,,, ;;. .1 1 I �:�'t. is
DIRECT VENT HEATER ..f 1[.,.:...il„ .._'I.-.- . 1 11 1 :-.,__,1 - . . ',.,-,,:1,:. ., .'. ,_ _.I _ . ,1
DRYER �f = �_
FIREPLACE ( ,-1 I I I
FRYOLATOR 1 I .. I 1 1 i 1 -_.11 1
FURNACE 1 ( ' _ � _ i. . Iri .1I
GENERATOR I .
GRILLE w i
INFRARED HEATER iiiimanwpaimummomemissume1w1
{ 1 i 1 1 I :j jI I;
LABORATORY COCKS '1 1
MAKEUP AiR UNIT I
ts_OVEN I:_ i ems. I I[1 _ I i 11 !
POOL HEATER �'� �� I I 1 ., �f 2,�i 1 �� I . ( _l
ROOM/SPACE HEATER I �1{ ,i r- .. I I I` i J. r - 11 (I .11
f _ I 71 ( 1 [i 1r 1 1 1I.
ROOF TOP UNIT �
TEST
UNIT HEATER I 1 �1 1 E ,(..- t :a., j 11 x,SOU r 1i. •i
UNVENTED ROOM HEATER ' .0 I' L�F ( i I
_c._.e. .,,.._I r .-_-,IT-,„],:_.,_.].s..rxrs�l..z��=.1 _r.._.�Li!::�_„.,11, � <..:_-- cY.:._
WATER HEATER-_ . I I' i
� �, J I1 11 !' 1.
OTHERJ__ I it lr J :- i r-, � `II L 1 f �7j i I
INSURANCE COVERAGE
I have a current I1abi10 insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES NO-LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY[D----. OTHER TYPE INDEMNITY [,,,,� BOND 0
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 El AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that ell of the details and information i have submitted or entered regarding this application are! nd a retg�to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued-for this.application will be in c I stye withal erttnen(provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
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PLUMBER-GASFITTER NAME L ...AV_d.r_, ........... ...�,�, ,�. LICENSE# a a' I-7 i SIGNATURE
MP11 MGF0 JP® JGF0 LPGI0 CORPORATION i #I` .�'"2 , PARTNERSHIPD#L, ` JLLC #T � 1
COMPANY NAME: 6��,� poi ,e. 1 �7^.r< ADDRESS! `�,� ikii,., ' � _' '�al)
CITY i�� .�,-. , _____4_,.. STATE
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