HomeMy WebLinkAboutBLDG-19-001036 tr.9t Jy r' A-P: P 4 �.1 ;Cti`P
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'Illag CITY I C. 1/ I- i MA DATE 9 ' t1vz I PERMIT#,/ ✓'
JOBSITE ADDRESS r : !,.✓,37.)--- . .:x'�,,, ...K..,. .11..1 OWNER'S NAME[ k A i/a . ,.,,i . :,,y,4 ..:,. .j
G OWNER ADDRESS El#L7, s< .::} .. M� 4.. JTE ._. _........,-]
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TYPE TR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL[ r�ry� RESIDENTIAL
CLEARLY NEW fl RENOVATION:0 REPLACEMENT:rr PLANS SUBMITTED: YESD NOD
APPLIANCES 1 FLOORS—) um ' 1 2 3 4 6 6 7 8 9 10 11 12 i3 I 14
BOILER _ if�� II �., 1 1" I II I7 1 # 1 f Ii il��l
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BOOSTER � li— I l 1" li i( II .:Z_ '' l . I . .I
(S'f hr,.i Y ;.a `z._ui, 3 .1..._. I.2Y1d_. L.11.fsY i vZ i:r.
CONVERSION BURNER i, 11 1(y } I
AZie,C .i,t.._ti .--,:z.e ,..,.tit ' .:ENV-_s� -.+' .r.s'.'4.14.lv. �- '
COOK STOVE i I I I� t o:110 a !
DIRECT VENT HEATER II 1[" :r_P `r f l .1[ ( i i if i „ _i.+
"'K?: i.BS-'I '2d5: < �A rs� ..a.d3i11f
7slti � - ,S i W( II ll. L . t.,_ `�^-t..s-1.v.SYY ..
FIREPLACE �r s i i� i'k l '�_i t
FRYOLATOR fifi 7 I ( 1 7( �fr {{Il {
`J root. I i .::, t1 S i , r i 14 L 1' F 7, 1 1 1 1 1+C. .). I I 1
FURNACE ply; y li �I. ( iI �I.. __
GENERATOR ,Fz,ti ,,I rrsZ: A�ax�1a�r. i7cc 1 tli I efYrl x I s !r( dl
GRILLE � � ( i .Iry�.. ;'+1. I� � )I � . II 1 � �I 1)i� I( 1 (�,.-, I� ilr ti�1i z ��
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INFRARED HEATER li f(' � !, (, I i I� II lI II }( I(� 1
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LABORATORY COCKS )i I r I( i . I 1l I ? ) 11 I I
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MAKEUP AIR UNIT ,.. � t . I.: .1, . : �..lnai1 .r . _tj�i l j I1�.�. ��-.rL.ri1 _:73i I ... i I
OVEN • I
POOL HEATER I1 II I 1 I I1 I fy1 f
�c:�'t N t 77 YS. r.S Ltz 41AYav La a RI 'il� �. J �Y 5 i 2 t M.1 i .�I c z' ic 1
ROOM/SPACE HEATER I'
ROOF TOP UNIT ` b d s` - s ,s.d�5 a,,� 4
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TEST li �� 1 :Jr:.
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UNIT HEATER ,_.4- -1(�.:�,.ill � 1I.:,::. -.N.4..I`l� :- - 1__��( 1 .. eI{:L..��ig .�t�i L _. . ,h-1r:� 4-1
UNVENTED ROOM HEATER r r 1
WATER HEATjR. _ f j i (i Iwo - i Wit„ r xs�L L I I 1 f I1 I
OTHER L. �l 1r_ l 71i 1_ _�...___ .�..,_ �f I I(� 1� �� 1, i� I I 11` 1 Ala
r+u ......._...-..... {��bf,1_2,t1&� � J 3",.,. .}a �I r7.. �.. ..Y t � ...
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INSURANCE COVERAGE
I have a current!lability Insurance policy or its substantial equivalent which meets the requirements of MGL,Ch,142 YES FANG CJ
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE of COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY r,;.}- OTHER TYPE INDEMNITY E. BOND Ei
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 Li AGENT Lam,(
SIGNATURE OF OWNER OR AGENT
I hereby certify that ell of the details and information I have submitted or entered regarding this application are trolnd acctlfallg to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in cony? !nine with aijPertlnent provision of the
Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. p" ( ,ff
PLUMBER•GASFITTER NAME 4 f ;a,.s °LICENSE# %'i.��t `� SIGNATURE
MP gq MGF Li JP El JGF[m) LPGI[,J CORPORATION( # ii-, j PARTNERSHIP LJ#L___._ j LLC #�,...,u.,,,�-
COMPANY NAME:L .,� J;'`'�` yz r �..J ADDRESS �'f ter," Ao�r�! , "1 O..' +J?%l 1.L t � r
CITY _ _ ��.._, itSTATE ZtP e� R TE . __.
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