HomeMy WebLinkAboutBLDG-25-339 1J. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
•
=-?l-. Xi CITY : V‘44 d�t I MA DATE; 1 PERMIT#D'-06- 2-S- 3 3 1
JOBSITE ADDRESS' 17 g-g74-G ti @(T, at- �,OWNER'S NAME B ra� $pr i i k 1 T i
GOWNER ADDRESS i _ r _ .- _ J.TEL tFAX'
TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL
PRINT rJ / RESIDENTIAL
CLEARLY NEW:,11 RENOVATION:L7 REPLACEMENT:S1 PLANS SUBMITTED: YES D NO i_,i
APPLIANCES 7 FLOORS-+ 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
___IBOILER .. :_J I. . I_—I — __I.— ! J _—( I _,®
BOOSTER —J—_I I, I . . _j°-
�� •1 . 1 . . 1 i
CONVERSION BURNER _J_I I=} 1 _ A A V -L7
COOK STOVE - .. -- -
DIRECT VENT HEATER E -
DRYER �lld...- , ! `—_I
FIREPLACE _� . i I E_ ®_J
JFRYOLATOR —Jl�I I�®® per,°+_+._.l- _ _i I®
FURNACE —I_—J_ I____I I .i _-1 i " . 1i-1
GENERATOR . ..I i_I__I._I__1..__J_1 _—I__I_J_1 >.
► GRILLE - i - i. - -i_ -_I__L_1, I_1_1'_—_ _I 1__ ..1_ :___ LI_ __J_ J
INFRARED HEATER J --- -_ _I_J . I _1_J:� _ I.— I _J—1'--j^J_J
LABORATORY COCKS ... I ' • _j' I_J -I t. __I. I_. I_1=J
O.
MAKEUP AIR UNIT I 1'j_I I . _�—J—I.—J - .. ___I �J /
OVEN :-"I . _.. i .. !:.- _. ! -_1 r1 I_- I_.1'___1___i____I�.I --I
POOL HEATER
—J—1—J_J�J.�.J_J._r1—J —1.rJ—�___I—J-J
ROOM/SPACE HEATER : ._..1 .. I______I .1__J I__.I . .. I ..:.I—I__J__I. I. 1 , .. SI
ROOF TOP UNIT _._I I _ .i . I•_ I____I_j':i_I__I_I I_j
TEST 1 I______II 1 I_J I I__...1_—I s . I- I -i
UNIT HEATER I I i i i . . ,. I_ _f_.____I-_-____I 1 i_i:_j_ LI
UNVENTED ROOM HEATER - _J i. i I I . " I___I_J__J _I i��j
WATER HEATER . . I_ _ I _� . .. .I .
OTHER _ .-y.. _. — ,. I
_�- I L n I I- I. 1: .
—J J
__.._._. ....__.._ I—1—J I LLI__1 I_L_LI - i I _J
—1.__1 _1 I
I—I�_►.__J ►__. 1 I_ -
kb
INSURANCE COVERAGElb _
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 O ;-�
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY _j BOND
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 I 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 � /9/5 Ted -E' I LICENSE#g� �iY
d SIGNATUR ��f
MP MGF=J JP D JGF.-] LPGI J CORPORATION`�I�t`�.3` ' 1 PARTNERSHIP #-- f LLC:_(#4 1
COMPANY NAME: /,e-/ r AL// /C_ I ADDRESS. /tli7/77i . -- --— - -- • -— ..
CITY 1-I/ „P/,/C'<I- ... . .. ..... ...__ ._._.. {, STATE'7Gr 1 ZIP: e675 {TEL 22 770 —�
FAX CELL; • !EMAIL LE -,,L,,,ae6 ' (3 '