HomeMy WebLinkAboutBLDG-17-001355 •I' ` MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WC
V- CITY jil- o_dh VA DAIS 12 ! �P ''ERjj6 ' -o o 5-5
JOBS(TE ADDRESS 7 0 DAr\C f f 1(G-1 D 4�• t 4 RAINER'S NAME CI i11/0/ c
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TYPE OR OCCUPANCY TYPE COMEtCIAL D ®IJCATIONAL 17, RESIDENTIAL Tr
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CLEARLY NEW:0 RENOVATOR 0 REPLAN:' • PLANS SUBMITTED: YES D NO
APPUANCES 1 FLOORS-, BSII 1 2 3 4 5 6 7 8 9 10 11 12 13 ',
BOILER
i BOOSTER - — , - r-
CONVERSION __ MR MIMI 1 no Jim PP- 1111ff___IINE=Mt
COOK STOVE __gip_mg111111_S is_ . am DIRECT VENT HEATER _—__ MIor______m -
1 DRYER MI Mt inMB_siff__ .- - __.
l FIREPLACE - __ -_'— � __ _ _ . _ _
FRYOLATOR - EMIEMI - __ ._ _MIN -- - -
FURNACE -_�.- -_ - _-
II r
I GENERATOR - _ ---- _ - - -_ _.__
1 GRILLE _ r
I INFRARED HEATER -_ _ __ ___ __W
LABORATORY COCKS ____-_air__Ili_ _ _
MAKEUP AIR MIT __MIN Malt INN 1111.1.1.gas Aug —OVEN n
POOL HEATER -
f ROOM/SPACE HEATER _
ROOF TOP UNIT Illi illik Mt -
TEST 21111 - -
UNIT HEATER
UNVENTED ROOM HEATER Mt� ____-•- _
WATER HEATER _ . � gar—— . M.
i OTHER
gm -- imam - - - _
- - -- —I IIIIIII
- - - - - -
INSURANCE COVERAGE
fI have a current liability insurance poicy or its substanfial egrivaleritttllicb meets the requirements of IIGL_Ch.142 YESX NO
1 I IF YOU CHECKED YES,PLEASE INMATE TIE TYPE OF OC�.V,,E�RAGE BY 0Et�16 TIE APPROPRIATE BOX BELOW
LIABUTY INSURANCE POLICY J O ER TYPE IMMINITY E] BOND 0
OWNER'S INSURANCE WAIVER I am aware that the licensee does set Menthe instwance coverage required by Chapter 142 of the
Massachusetts Genera Lawsjrand that my signature on this pent*appkaboet waves this requirement
f. r CHECK ONE ONLY: OWNER AGENT •'
SIGNATU1E OF OWNER OR AGENT
I hereby certify that all of the details and infotrnabon I have submied or entered regaining a is appiration are true and accurate to the best of my knowledge
and that al pksnbing work and instaFabons performed wider emperor'issued for this appicaion ail be in compliance - ,ertinent provision of the
Massachusetts Slate Plumbing Code and Chapter 142 of the General Laces_
PLUMBER-GASFI I I ER NAIrE i 11 A Re L.e-i.U1E/j �,,(I UCENSE s - SIGNATURE
MPX MGF I ,�D JGF j-LPG!LI COF�tATION,��TTT 4717 {PARTNERSHIP 0/4 I LLC r'#
COMPANY NAME r f4 gfe-t titali A ; a3 ,i.�n iirJF
CITY 1}Jp,n v/1ie_ ! STATE MA, 1ZF 'i)7602- fra;c:it- n-53- i
FAXszW qt'---SSo 1 m II IBAMILDECOStil aOII.4 _ail
SOUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT N
PLAN REVIEW NOTES