HomeMy WebLinkAboutBLDG-24-396 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
? =!i= crr( A✓ �— , MA DATE; 4 - 'I(PERMIT#,43L&,'2/- 39h
JOBSITEADDRESSI -7,0ve ytf 1J�f T
G I OWNER'S NAME EAI'S QA4r r
G OWNER ADDRESS i 3k/ Coil C. V'L C'S _ — 17EL'_ FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL;,_( EDUCATIONAL J RESIDENTIAL
PRINT /
CLEARLY NEW:,y� RENOVATION:'Li REPLACEMENT:;_I - PLANS SUBMITTED:YES i,] NOD
APPLIANCES 1 FLOORS-. BSA 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —I_-(_J f f L-1-1J i I r t - t _ I
BOOSTER _:-_J—J_j-_I f t;-1'. _1 —].J I f I f
CONVERSION BURNER J I_!_I—I f l__J 1 ._I f
COOK STOVE ,_J_1-1—t-j-J J-J _J_ -J __ ' _I . I f
DIRECT VENT HEATER _ _I_1_J.____1._j J�,,—J_j—I J_J_J f
DRYER• J_1_1—J�_1-1�_J--f�—f__J I - I
• FIREPLACE —JJJ LJ,JJJJ—JJJJ-J I
J FRYOLATOR —J_ -1—J _I I . I J-17_1—1_-1 J_l I-.--I
FURNACE _J—J—J_ I-1 - ILL! —1 I__I_ - I
IPGENERATOR _I J_I_J J,_J�—1_1—_ J�.—I I
GRILLE _J f. r 1—J.---I _J'_� I—J�'_J
INFRARED HEATER •_J —p-J—J I_I_�__��I_J ____J____I I !
LABORATORY COCKS _I • 1 J�—-J JI J -._J_J J J—J J
MAKEUP AIR UNIT f_-J—J_1 J_ J_J J I_ .I J_J I
lOVEN J I I J II_J--1_I_J LI_J J_I�I_I 7
POOL HEATER _J J_11—6__I__I___._1_, _1_ J—J— —J J— J J I
ROOM/SPACE HEATER ____! jj_J_I_J__I_J —I__I I_J__-_1 I_I - I
ROOF TOP UNIT _,I_I —1 I_I_J—J_J' ( —+ I i I
TEST J J I_I L —J_.__I—i LT E. 0 ;1 J �/f 7. 0
UNIT HEATER _I _J I_f --I__J J —I,--1 - I -
UNVENTED ROOM HEATER J I i i—.J—I_;---J '- n h u l'',2� i f WATER HEATER _ ____1__J J.. J J J -I___ I - I
OTH R i - __...pp;;' _I—J_Y I J i_I J—J_I -J—1_11 I - f
C.! !�.•.-aflreJ'r i-I .- I I_J-1 J'-1__J ,i,�r-PAk91ni Nt
I_J� I_JJ-1J_J__J I -1 6- ..- - -I
11. I_I r _ .I—i F _J__J�I-J__i_____I_1J I-1
ie INSURANCE COVERAGE
b I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES O;J
L I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY T-1/ OTHER TYPE INDEMNITY_i BOND f.J
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-II AGENT J
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.
PLUMBER-GASFITTER NAME //,4�!c V f v{t � �I LICENSE#eiQe"/I SIGNATUR
MP Z'MGF J JP D JGF:1 LPGI_,J CORPORATION roltry.Yy7-1 PARTNERSHIP:.1.#I I LLC:,_-jc f
COMPANY NAME----7/if /1.. c L ADDRESS, Ill'Q//l, S —— -- ——
CITY j�.PAIOK1G__. .--- -_ _f STATE;OW_I ZIP��O.?G%3{TEL �5 Yr�'e
FAX ----.ICELL'. • I EMAIL!(JJ /LQ dNI .[(��_
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ _ PERMIT#
PLAN REVIEW NOTES
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