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HomeMy WebLinkAboutBLDG-20-002655 i ? MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 144410U711 MA DATE /Vdr1 '( 2019 PERMIT# G�D 31y� JOBSITE ADDRESS 2-2 3 2TI- (o 4- OIMVER'S NAME 00 y/„n.j/� i_„i` GOWNER ADDRESS TEL SbZ ?L2 "Pa-FAX TYPE OR PST OCCUPANCY TYPE COMMERCIAL[]� EDUCATIONAL ❑ RESIDENTIAL 0 CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑ APPLIANCES Z FLOORS BSM 1 2 ; J 5 F 7 6 9 1(l 11 1� BOILER 2 13 iq BOOSTER _ CONVERSION BURNER COOK STOVE 2 DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR ' FURNACE --___I GENERATOR _I GRILLE INFRARED HEATER /_ 3 LABORATORY COCKS l Q„�y MAKEUP AIR UNIT + J' OVEN I/��U --� POOL HEATER ROOM ISPACE HEATER ROOF TOP UNIT R 'thiy E UNIT HEATER _ F"' (INVENTED ROOM HEATERTEST Ly" WATER HEATER Cr?_) OTHER -; . ,— tPAF T -- - 2",u tE/I ACt a' © • - INSURANCE I have a current liability insurance policy or its substantial equivalent COVERAGE nt whichmeets the requirements of MGL.Ch.142 YES 2110 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 0 LIABILITY INSURANCE POLICY Er OTHER TYPE INDEMNITY 0 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. , SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER❑ AGENT❑ 'i. 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 LICENSE# SIGNATURE MP El MGF❑ JP 0 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# tic 0# ?I' �n v COMPANY NAME /3f 1 I c( W''+rPO.y ADDRESS VS— m.s/.✓ -P.u,C7- CITY s/1.u0 wILI, STATE M4 ZIP Z.S. 7 TEL SV k -276 /oos' FAX CELL 77V Ye7 7/70 EMAIL 4///1 S, .r 330 (✓� Erma//,. (,'.7..,.. Z` ` HU. PAGE FOR IP,ISPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT E fl FEE: $ PERMIT # PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ro CITY `144-''7 DUaf a ,l MA DATE A/OJ t{ ?a t 4 PERMIT# _�PSU JOBSITE ADDRESS 2 Z 3 ► r e- (p 4- OWNERS NAME OC e) _ ___q_».,.n t ,,/ GOWNER ADDRESS TEL roe Z6z 996zPAx • TYPE OR ---� PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ElRESIDENTIAL El CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑ APPLIANCES 1 FLOORS—, BEM 1 2 3 4 5 6 BOILER 9 9 10 11 12 13 14 BOOSTER CONVERSION BURNER 7 /0 COOK STOVE .2-. �r0 6 dYe-� DIRECT VENT HEATER DRYER t/� A-/rj s J o 6 b — FIREPLACE jrs 1 y FRYCILATOR d FURNACE �'T ) GENERATOR` GRILLE Co ‘� INFRARED HEATER ! \ LABORATORY COCKS R` 1-1) `j t �P //�' MAKEUP AIR UNIT �1 � �, 1\ ' ,; i • OVEN �QPP / ' POOL HEATER -� �/� • ROOM/SPACE HEATER ROOF TOP UNIT e�%'� 4f° E TEST _. . .._. UNIT HEATER ,�_�,�'� 4y�}{} • _ UNVENTED ROOM HEATER �IStV �'L"' WATER HEATER OTHER -. JEPAF1Al STtiu4.n T1►3 to ! --—--- - II / y INSURANCE COVERAGE S I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES uio I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 0 LIABILITY INSURANCE POLICY Er 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. •�. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT r,1:• 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 •5 and that all plumbing work and installations performed under the permt 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 LICENSE SIGNATURE MP El— MGF 0 JP❑ JGF 0 LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME 31-µ y t C.Jal pow y ADDRESS Ser / i.✓ J;- uT CITY St3a0 wILI, STATE MA ZIP 7LTC 7 TELLo>: 77r io — FAX CELL 77V ' 7 9/70 EMAIL 4i//�4.1 .2. 330 e peat/. ��,..,