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HomeMy WebLinkAboutBLDG-22-004033 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK €s BLDG 22-004033 CITY kr,r EA MA DATE January 21,2022 PERMIT# JOBSITE ADDRESS 132 INDIAN MEMORIAL DR OWNER'S NAME Luke Cyr G OWNER ADDRESS TEL, TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INCEMNITY❑ 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 signatt re on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered'egarding 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 Thomas Coughlan LICENSE# 8529 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: THOMAS J COUGHLAN ADDRESS. 48 HERITAGE DR, CITY WALPOLE STATE MA ZIP 020812240 TEL FAX ]CELL EMAIL S31ON M3IA3H NVld #II1A1N3d $ 33d ❑ ❑ 111A1213d 3H1 SV S3AH3S NOI1VOIlddV SIHI oN saA S310N N01103dSNI IVNId A-NO 3Sfl H0103dSNI HOd 3OVd SIHL S31ON NO1103dSNI SVO HJf1OH _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK :II 1,- C ' V E __ _ _...._.. _--__. _-...____..._ _.-_.._.._._.�� _ _ W = , 1='= '�.-' `- ' CITY .- yff,tmwm., MA DATEPERMIT# 2 f-t o 3.? - � JAN 2 C a TE , D ESS /3�. .rivb%/t�V � o/11Ai. ) QWNER'S NAME . �C.0 ke a% ^— _- - I Bu I L ...- G - MA/ ;Me ESS —. .�_,. ---= -- -- - - - - - - - TEL JOB- - - i. S- _S .FAX----------1 u _ 'PRINT PE COMMERCIAL;] EDUCATIONAL 1:1 RESIDENTIAL' CLEARLY NEW: ,i RENOVATION: U REPLACEMENT:g PLANS SUBMITTED: YES 3 NO' APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _-_-J ._ __J _.J ____ _._._1 I 1 I I _ __ _.____i_I I 1 _ I _ I BOOSTER _ _ I r 1 , . _1 —J _— t— __I _i•— _ 1 —____I CONVERSION BURNER i I I I ; 1-__�_j. i I _____I I ' _I:- i _I COOK STOVE I _i I - __._ I . 1 __Li _—J. ___1 �` _ .___..I —1 _.1 DIRECT VENT HEATER i i _i —_# _�; --j -_I .__I -i ! _1,__J DRYER - - ' --I -----i, _---1 I --� 1 _i --i 1 1 _-1 I —1 FIREPLACE I I _ I i 1 1 . _ I 1 ___ 1 - I FRYOLATOR -_- ' 1 _� i -. i I - ..-. ..1 : I I i _ _.___-I ____ I —___A J FURNACE -_J _____I •_____J - - 1 1 _____ - I - l - -- i ____ I _ __I ___-__J ...____I__,- I GENERATOR _I .i i - r .._.__f 1 __ ____..1 i-- GRILLE - - -• - - - - - INFRARED HEATER _.- . _ -1 1 ___-! _I ,J _� 1 �j �_1 LABORATORY COCKS 1 - I _ -____i I --1 1 ._I ______1__ J I __ I 1 r it MAKEUP AIR UNIT' . _ --�---� - __. - I ___ 1 . I_J J ----1 1 1 ____.____I I 1 OVEN - I _..y_ s i i ____1 _ 1 �_{ ___...I ._I _ __._._I _ 1 .____...._I i ___-_.Y I M-.._1 1 4,„ POOL HEATER I �I _.._.,_.,! ______-J , �i .._�_-_! ____, I ; _I ____ ...1 _ _I —.__._I _J J __ 1 ROOM ! SPACE HEATER _ ._ i r I i i _ _ I i r ROOF TOP UNIT _ ..._...I _ .. -.-._ -,_; 1 i ! I i _.._.� ��..._. _..— _...mod ! TEST _.__..... 1 _t __. , ___.. _w_ I _._._ ; __ _.. .--- _ r, UNIT HEATER s t , . _ . ; . : . . . f _. a� ..._... ! M ..—__' a_ .. _ __._ -__.._+ _ o; _I _. ; ..,.. ` _-____J 4 _____J UNVENTED ROOM H EATER _.._� _- 1 _r _____rt ___.' ; _--.-_._1 _._-.---_J •____J ____1 ______I 1 _-___,I _._____i _._-__J WATER HEATER j I . j. E 1 , _._. ._J . . �� . i I i I i 1 I --OTHER - - - � . � I ... i•w I -.I : . 1 . -y — _ ----- __.__ .__ • I 3 . I J L - . " - - - 1 ��I i j I I 1 _-- I I ? I I I _ 1 i _ _____1 __._ 1 ____I 1 _ ! ___.. 1 I 1 _1 1 I ! i ._i ...._..._.. ._ _._ ... .S 1 S I t INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES L_i NO Xi I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 'LI BOND I_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 .__..1 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 pro ' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. W PLUMBS -GASFITTER NAME 'tiles' 1 kg0oa ,4A I LICENSE # 6�9-L4, SIGN-,1 inttels 6 !i RE MP MGF �.,J JP JGF J LPGI _J CORPORATION I ` - 46b 7- ! PARTNERSHIP ^.r.1# LLC 1# 1 COMPANY NAME AIL f,Q3 7'GCrt; I ADDRESS 3 Q M eL/5 S. " . .IV CITY V4te b1O ( J STATE M f"ZIP C);26 1 - TEL S6 % --- - - 1. FAX I CELL, - EMAIL: "—t0.4/9W �' • CD Gj(,4iL . COAA, I II ii 3 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT D1=1 FEE: $ PERMIT$ PLAN REVIEW NOTES %%XVI V s V3.110..C.c