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49-061 (2) FIENDALE RD PTA- �)Z I-1 7 ? (Vr Map:Block:Lot: COMMONWEALTH OF MASACHUSE'T'TS II49-061-001 CITY-OF NORTHAMPTON Permit: New Build PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) 0 BUILDING PERMIT Permit# BP-2021-1755 PERMISSIONIS HEREBY GRANTED TO: Project# contractor: License: Est. Cost: 295000 103381 Const.Class: Exp.Date:08101/2023 Use Group: • Owner: MS HOMES LLC Lot Size (sq.ft.) Zoning: Applicant: MS HOMES LLC Applicant Address Phone: Insurance: 21 WEST SCHOOL ST 4132440336 WEST SPRINGFIELD, MA 01089 ISSUED ON:11/01/2021 TO PERFORM THE FOLLOWING 1VORIi: NEW SINGLE FAMILY HOUSE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rou*h i, 7 Rough• - 1 _1 House # Foundation: Drive% Ffn . Final: �' ,t)- Final: Rough Frame:0,>V - � /t4-�4, - , ;ire Department Fireplace/Chimney: Rough: Oil: � Insulation:(;,; „ '3. ie-Z2- )!t1 0*.rfrTFA.4 Zt oke• !j a�-3 01a- Final:t'•K 11- it-23 a/ THIS PERMIT MAY BE EVO ED BY THE CITY OF NORTHAMPTON UPON VIOL,G TION OF ANY OF ITS RULES AND REGULATIONS. O Signature: 1 , F1 W 44, ) 1 y r z :._ Fees Paid: $1,100.00 \ 212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner N1OR1 ILV . EMrt ct E.* ` R1.V*5 .� • FRoncT S i fMRS Nib( )Lk Y. r:Zroa_,3rf-1--H icooti 5 jIm c 4ccx-55 .7 1404, _ #,� , The Commonwealth of Massachusetts %` } >.' rTl) of Northam ton City p �� Certificate of Occupancy In accordance with 780 CMR, (The Ninth Edition of the Massachusetts Residential Building Code) this Certificate of Occupancy is issued to the premise or structure or part thereof as herein identified. Identify Name of Building of Space Within, Building Owner, or Permit Holder Certificate No. Issued to MS Homes LLC BP-2021-1755 Identify property address including street number, name, city or town and county Located at 241 Glendale Rd. HERS Rating Florence, Hampshire, Massachusetts 55 Use Group Classification(s) Single Family Dwelling Unit This Certificate of Occupancy is hereby issued by the undersigned to certh'that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the use as herein described and in conformance with any and all conditions as identified below. It shall be posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to comply with conditions or,tampering with the contents of the certificate is strictly prohibited. Conditions of Use Single Family Dwelling Unit All fire protection and life safety systems must be maintained, and all means of egress must be kept clear Name of Municipal Date of Final Map/Plot Building Official Kevin Ross Inspection 01/11/2023 Signature of Municipal Date of 49-061 Building Official /717--Y— Issuance 01/12/2023 Home Energy Rating Certificate Rating Date: 2022-1 1-15 Final Report Registry ID: 405027602 Ekotrope ID: P2INX8Gd HERS® Index Score: Annual Savings Home: Your home's HERS score is a relative 241 Glendale St performance score.The lower the number, 75 p 5 the more energy efficient the home.To Northampton, MA 01062 Builder: am learn more,visit www.hersindex.com4 Relative to an average U.S.home MS Homes LLC Your Home's Estimated Energy Use: This home meets or exceeds the Use [MBtu] Annual Cost criteria of the following: Heating 74.2 $750 2018 International Energy Conservation Code Cooling 0.6 $13 Hot Water 2.6 S62 Lights/Appliances 24.7 $531 Service Charges $108 Generation (e.g.Solar) 0.0 SO Total: 102.1 $1,464 HERS Index Home Feature Summary: Rating Completed by: Sere foam Home Type: Single family detached asr) Model Colonial Energy Rater: Paul DellaTorre RESNET ID: 8776762 Existing aao Community: Northampton Homes tso Conditioned Floor Area: 2,998 ft2 Rating Company: Energy Compliance Services t >{ rm i aw Number of Bedrooms: 4 27 Hudson Dr.Southwick MA 01077 ,,,�- Reference 110, 100 Primary Heating System: Furnace•Propane•95 AFUE 413 427 2423 Home 0.0 Primary Cooling System: Air Conditioner•Electric•13 SEER Rating Provider: Building Efficiency Resources Ieo Primary Water Heating: Residential Water Heater•Electric•3.45 UEF PO Box 1769 Brevard,NC 28712 7O House Tightness: 1 187 CFM50 i2.91 ACH50? 800 399 4620 ,, `i° Ventilation: 80 CFM. l0 Watts d This Hone Duct leakage to Outside: 18 CFM;a 25Pa€0.74/100 ft21 Above Grade Walls: R-21 S a l xo Ceiling: Attic R-49 f f �: '.� Zero Energyi9 Window Type: U-Value:0.3,SHGC:0.28 / 2((i 1�P�(�t �� � �e Ho 0 Foundation Walls: R-13 Paul DellaTorre,Certified Energy Rater „_i3®ram AP' u"a""g' Framed Floor: R-30 Digitally signed: 11116/22 at 2:11 PM ro Ekotrope RATER-Version:4.0.2 033 The Energy Rating Disclosure for this home is available from the Approved Rating Provider. This report does not constitute any warranty or guarantee. Home Energy Rating Certificate Rating Date: 2022-11-15 Final Report Registry ID: 405027602 Ekotrope ID: P2INX8Gd HERS® Index Score: Annual Savings Home: St Your home's HERS score is a relative 241 Glendale 5 performance score. The lower the number,5 Northampton, MA 01062 the more energy efficient the home.To Builder: learn more, visit www.hersindex.com "Relative tv an average U.S.home MS Homes LLB Your Home's Estimated Energy Use: This home meets or exceeds the Use [MBtu) Annual Cost criteria of the following: Heating 68.8 $695 2018 International Energy Conservation Code Cooling 0.6 $14 Hot Water 2.6 $62 Lights/Appliances 24,6 $528 Service Charges $108 Generation (e,g.Solar) 0.0 $0 Total: 96.6 $1,407 HERS Index Homo Feature Summary: Rating Completed by: nw.r,wp Home Type: Single family detached no Model: Colonial Energy Rater: Paul DellaTorre Existing 14o Community: Northampton RESNET ID: 8776762 Homes t30 Conditioned Floor Area: 2,998 ft2 Rating Company: Energy Compliance Services tzo Number of Bedrooms: 4 27 Hudson Dr.Southwick MA 01077 no Reference I. Primary Heating System: Furnace•Propane•95 AFUE 413-427-2423 Nome 90 Primary Cooling System: Air Conditioner•Electric•13 SEER Rating Provider. Building Efficiency Resources eo Primary Water Heating: Residential Water Heater•Electric•3.45 UEF PO Box 1769 Brevard,NC 28712 7Q House Tightness: 1 187 CFM50(2.91 ACH50) 800-399-9620 r^^'•tie MI 6°"AttVentilation: 80 CFM•10 4'Yatts so ,,3 This Horne Duct Leakage to Outside: 18 CFM n 25Pa(0.74!100 ft2) Above Grade Wails: R-21 �� _ zo Ceiling: Attic.R-49 t Zero Ever to Window Type: U-Value:0.3,SHGC:0.28 t a feet a T '�G Home 0 Foundation Walls: R-13 Paul DellaTorre,Certified Energy Rater ox,:aS•., `' Loss Energy Framed Floor: R-30 Digitally signed: 11/16/22 at 2:11 PM 0 e kot ro a Ekotrope RATER-Version:4.0.2.3033 The Energy Rating Disclosure for this home is available from the Approved Rating Provider. This report does not constitute any warranty or guarantee. Energy savings calculated without modifications to the energy model(As Modeled) 241 Glendale St Northam•ton MA HERS"Index Score: Rating Date: Nov 15,2022 SS HERS Registry ID:405027602 Annual Estimates: Rating Company: Electric(kWh): 7,9310 Energy Compliance Services ProPropane(Gallons): 764.1 Rating Provider: P (Tons): . Budding Efficiency Resources Rating Provider Address: Approx.Energy Cost: $1,407 PO Box 1769 Brevard,NC 28712 HERS Index Home Feature Summary: •ew«c ae xy Single family detached,4 bedrooms,2,998 ft2 Heating:95 AFUE i1omCS asp Cooling: 13 SEER Hot Water:3.45 UEF Air Leakage: 1187 CFMSQ(2.91 ACH50) ittVentilation:80 CFM.10 W Duct LTO: H.okini, 18 CM!@25Pa(Q.74t100ft2) Above Grade Walls:R-21 Ceiling:Attic,R-49 Home 0 Window:U:0.3•SHGC:0.28 cmaxa WW1 t."4""T Foundation Walls:R-13 Ekotrope RATCR Version ekotrope 4_0,23033 mt.raver#stennnt 000ntttutr arty•worattty cx guararstre. IECC 2018 Performance Compliance Property Organization Inspection Status 241 Glendale St Energy Compliance Servic 2022-11-15 Northampton, MA 01062 Paul DellaTorre Rater ID (RTIN): 8776762 Model: Colonial RESNET Registered Community: Northampton Builder (Confirmed) MS Homes LLC 0217_Sergey Savonin_241 Glendale Rd_Northampton_221014 0217_Sergey Savonin_241 Glendale Rd_Northampton_221115 Annual Energy Cost Design IECC 2018 Performance As Designed Heating $2.749 $2,882 Cooling $96 $66 Water Heating $125 $126 Mechanical Ventilation $62 $13 SubTotal - Used to determine compliance $3,032 $3,087 Lights &Appliances wiout Ventilation $1,027 $1,027 On site generation $0 $0 Total $4,059 $4,113 R405.3 Source Energy Exception:The proposed home uses 1.51 MBtu LESS source energy than the r-ference home. • Requirements • R405 3 Performance-based compliance passes by 1 4% The proposed house meets the IECC 2018 Performance r-ference energy bill requirement by 1,54 62(1 51 ME3tu) 6) R402 4.1.2 Air Leakage Testing Air sealing is 2,91 ACH at 50 Pa,It must not exceed 3 00 CH at 50 Pa 0. R402.5 Area-weighted average fenestration SHGC Are weighted average fenestration SHGC is 0 332.The aximum allowed value is [No Limit] 16 R402 5 Area-weighted average fenestration U-Factor At least 4 R404 1 Lighting Equipment 90 0%of fixtures shall be high-efficacy lamps,cur -ntly 100 0%are high- efficacy • R403 6 1 Mechanical Ventilation Efficacy Mandatory code requirements that Mandatory Cnecttitst are not checked b Ek b y otrope must e met. 2018 IECC Mandatory Checklist must be checked as corn.lete 1RC M1505 4 3 Mechanical Ventilation Rate • R405.2 Duct Insulation All ducts outside the thermal envelope must be insulated 1. at least R6 0 Design exceeds requirements for IECC 2018 Performance compliance i.y 1.4%. As a 3rd party extension of:ne cc.ce jurisclinon u,iong these reports.I certify that this energy code compliance document has been created in accorda ce with me requirements of Chapter 4 of the adopted International Energy Conservation Code based on HAMPSHIRE County If rating is Projected.I certify that the building design d scribed herein is consistent with the building plans, specifications, and other calculations submitted with the permit application if rating is Confirmed. I certify that the address -ferenced above has been inspectedltested and that the mandatory provisions of the IECC have been installed to meet or exceed the intent of the IECC or will be verified as such by another party. Name: Paul DellaTorre Signature: O ( 11/16/2 Organization: Energy Compliance Services Digitally signed: e2 at P:11 PM Ekotrope RATER-Version 4.0.2.3033 IECC 2018 Performance compliance results calculated using Ekotrope RATERS energy and code compliance algorithm Ekotrope RATER is a RESNET Acaedited HERS Rating Tool All results are based on data entered by Ekotrope users. Ekotrope disclaims all liability for the information shown on this report AA, .0*4 414.1,1***.**t° . .°4'$f,al se'd,,1'1' .*. °Of t f$'ff..k.4,1*if^ * .f*t**trt 14 4*4,a't. .*, ''t't Ai.'***4**4*A, AA 1. .*4 A ...'' A44.11A °4.` .4.," ,44'' . A 44'' ''.1.t i,444. A*.• ..44.A. A' A 4.A .,4*.t'i :1,1 .4,e' •.0. .<, ,4,* ....— —,*,4.11 .'t.;°° :....°, ,,,A.,, 44 y to Y°. it '' tt ' • ' *A y *4 . ' ** Y *11 '. ." *1." *4 Y , t* Y cc ', <' s* • *4 A°' .° .** •' ..... ' ,,„. '. 44. ' .4.* ' .44° .,° ... ... 241 Glendale St ....,, ....‘ ... ,.. .: „ .... ::.... , Northampton, MA 01062 . ... ,z,.. ...: Builder: MS Homes LLC °:-... . ....- 1 d Moe : Colonial Community: Northam.ton .,. -.., --- --- ,... -,.. THIS HOME IS CERTIFIED TO MEET THE i ...„. ,..... ... . .— ... .. ... .. ...., . .. 7..... 2018 INTERNATIONAL ENERGY CONSERVATION CODE . , .... .... -.. .... ;..:. .„. .,...,s. .. ,...,. . .: : . ..- Building Features -,,-- ... ... ... . ... .... . ... ... -- .1-..' ). Ceiling Attic, R-49 Duct Supply R-8.0, Return R-8.0 .-..- ... ... -. Above Grade Walls R-21 Duct Leakage to Outside 18 CFM @ 25Pa (0.74/ 100 ft2) ..- -.:. ' -... ....: ...... Foundation Walls R-13 Total Duct Leakage 179 CFM @ 25Pa (Post-Construction) :-.. .... ' ”,.. `....; ° Framed Floor R-30 Heating Furnace -Propane•95 AFUE 7..... ..,-,. ... , .... : Slab R-0.0 Perimeter, R-0.0 Under Cooling Air Conditioner • Electric• 13 SEER .... ..,- -.. Infiltration 1187 CFM5O(2.91 ACH50) Water Heating Residential Water Heater• Electric•3.45 UEF ... 4.. ...,4 :..: Window U-Value: 0.3, SHGC: 0.28 -•. . .:-. • .... ..-..4•:* *::: , .4.. As a 3rd party extension of the code Jurisdiction utilizing these reports, I certify that this energy code compliance document has been created In accordance with the requirements of . .... .. ...., -- Chapter 4 of the adopted international Energy Conservation Code based on HAMPSHIRE County.If rating is Projected.I certify that the building design described herein is consistent .-- - --• the building plans specifications,and other calculations submitted with the permit application If rating is Confirmed.I certify that the address referenced above has been inspectedittested -• .... and that the mandatory provisions of the IECC have been installed to meet or exceed the intent of the IECC or will be verified as such by another party, ..., ... •-- -- Name: Paul DellaTorre Signature: Pau i Pella 7;9 1)40 ...,..- ..., Organization: Energy Compliance Sewices Digitally signed: 11/16/22 at 2:11 PM . . . .--. .., .,- ..-, .-- . -- ..- :-. Ekotrope RATER-Version 4.0,2.3033 ... ... ‘.. . 2D18 IECC compliance results calculated using Ekotrope RAT ER's energy and code compliance algorithm. .^ •... ., '** Ekoirope RATER Is a RESNETActredited HERS Rating Toot At results are based on data entered by Ekotrope users .., t.:.:• ) Eko&,)pe dscWrns s liabilly ff Ih.:,inf,:qmation hown on this report. . *:• ... . . " • ... . . A.. • ., $ • ,.., . , %.,, Cc ,.• ` SI ff ' •. %II .. Of cc ; 4 f • ... ,.., ,f...5..,..,*,*CC.,, '. ',' ',,,,, .",7,...".t: .?..:, ''.:S.,,,f...$7g.1,g#f'.1:!'1,,,' ''..:'..$$f,:$.11*11$Cf$:!‘ 1,:` ''.!!'f•f.':;.. ...:". ' .*:.,...',", .t“r*:' " '''..."'74'......:!" .,' ':::°.••:':' .•,'.,,. -'••+,',. .i*.•,., , ..,*,f.•., 4,$:$,S.'^ •',1y.,11,'$,..., ,f,* ..,*. ••.* '• ,' '• '•* t',.,, *. * •°,....+1,,,.,.,.$.s!, , . • - IECC 2018 Label 241 Glendale St Model: Colonial Ekotrope RATER- Version: 4.0.2.3033 HERS®Index Score: 55 Ceiling: R-49 Above Grade Walls: R-21 Foundation Walls: R-13 Exposed Floor: R-30 Slab: R-0 Infiltration: 1187 CFM50(2.91 ACH50) Duct Insulation: Supply:R8, Return: R8 Duct Lkg to Outdoors: 18 CFM �1a 25Pa (0.74/ 100 if2) Window 81-41, 'x' SpeOi U-Value: 0.3, SHGC: 0.28 Door: R-6 Mechanical Equipment Specs Heating: Furnace • P°opine •95 AFCE Cooling:Air Conditioner • Electric • 13 SEER Hot Water: Residential Water Heater • Electric • 3.45 UEF Average Mechanical Ventilation: 80 CFM Signature: __4r a c-7t/0 --- ,-,E r; r1/-5---‘C-k•*--1.3(17_,3 - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - ff %gz CITY IOf i f✓j� r✓ IA. DAT PERMIT#PP23 22-OD3 0 l d4jJpD;v JOBSITE ADDRESS '2_4i/ g!�r� OWN RSNAME pfCe�/ 7,1/ )/i /1 Prn OWNER ADDRESS: TEL: jj3,;,?4, EAI: TYPE ORN OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: [ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES D NO❑ FIXUTRES Z FLOORS Bsmt 1 {2 3 4 5 6 7 8 9 10 11 1 13 14 BATHTUB 1 CROSS CONN DEVICE _ _ _ DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR I AREA DRAIN INTERCEPTOR INTERIOR _ _ KITCHEN SINK I LAVATORY I ROOF DRAIN — --r__ _ SHOWER STALL PLUM-RING-8 CMS+NSPECTOR SERVICE I MOP SINK NORTHARIIPTON TOILET j I APPROVED- NOT APPROVED URINAL c7 ✓i , WASHING MACHINE CONNECTION _ I- _ _ _ WATER HEATER ALL TYPES , • _ _ WATER PIPING INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES J NO If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ 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 El AGENT El 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 accurat•to the best of ii Knowledge and that all plumbing work and installations performed under the permit issued for this application will b• • $ ':,:u,o,. • . •ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L// PLUMBER NAME: Vitaliy Davidenko LICENSE# 15996 SI NATURE COMPANY NAME: Advanced plumbing Ilc ADDRESS: 1505 Southampton rd CITY: Montgomery STATE: _ MA ZIP: 01085 FAX: TEL: (413)352-8518 CELL: EMAIL: MASTER❑■ JOURNEYMAN El CORPORATION El# PARTNERSHIP El#_ LLC 0# 3461 7 -10 y„1�� o/94 / c_lcirt 77L1 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F Mt f-m J CITY Northampton I MA DATE 03/18/22 I PERMIT#6 ?2o2 2 O I`e`4 ,„IOBSITE ADDRESS 241 Glendale Road OWNER'S NAME MS Homes LLC GOWNER AdDRESS 231 W School Street,W Springfield MA 01089 I TEL 413-244-0336 IFAX TYPE OR �r PRINT °OCCUPANCY TYPE COMMERCIALS EDUCATIONAL ElRESIDENTIAL 0 cc I CLEARLY VEW: RENOVATION:El REPLACEMENT:Q PLANS SUBMITTED: YES El NOE APPLIANCES 7 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER j BOOSTER _ _ _-I .1 CONVERSION BURNER 5r r f 1 COOK STOVE I DIRECT VENT HEATER J_ J j U „ i 1 J 'I DRYER J -_ . .I - J - Al ) )-- FIREPLACE FRYOLATOR 1 � FURNACE J1� 1111111 IMI ---nil�� GENERATOR GRILLE J J ,( J `,J INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT J ... _. j e_. j j 7 -liti,n .lJ('i N (' S IN .I'L JI UHJ OVEN 1RT ra lvn 10 POOL HEATER I _ _ 1 1 I i WE f • .pR 4 Y i ROOM/SPACE HEATER ROOF TOP UNIT J J 1 .i I TEST IIMICIIIIIMIIIIIIIIIIIIMIIII:_11011[— UNIT HEATER J j., I . FINJ - . J ;J- UNVENTED ROOM HEATER11111111 WATER HEATER OTHER IUG Line J_i_J I E lumfammimion INN moNommu IIIIIIIIIIIIIIIMIIIII INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO EJ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY © BOND El 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 El AGENT ID 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. c.✓f._> PLUMBER-GASFITTER NAME Stephen Constantine LICENSE# 3063 I SIGNATURE MP 0 MGF® JP® JGF® LPG'El CORPORATION®# .PARTNERSHIP®# J LLC E# _ _I COMPANY NAME:Osterman Propane LLC ADDRESS 339 Amherst Road CITY Sunderland I STATE AM IZIP 01375 TEL 413-549-1000 FAX N/A CELL N/A EMAIL N/A ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# - ( "1(2-.27/ PLAN REVIEW NOTES S-f 0 ✓ C e `�- likes v=�/g.z T .ice ` ,w -vd /-i - 2,3 • -e- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' �=Ti � o( � .3..._ C s4t=�— CITY (( / cZ/J/f MA DATE d� /X2 PERMIT# /' r'3oZ'3 ?6 JOBSITE ADDRESS C P/� �/ '�(�// 6......._ L� �-� OWNER'S NAME SS �- -. 6,V0.!t.y A_ ...... GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL LI PRINT CLEARLY NEW: V RENOVATION: ......; REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER H. FC r 1 v COOK STOVE V r�.. .- DIRECT VENT HEATER ' -- 1 DRYER • 3 f i FIREPLACE / � .T .._%P22 FRYOLATOR I FURNACE /. L_ GENERATOR i ___., �I V.., T4'lis, �A N.-0.ona5 ' Ufl P.,,r, GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT PLUMBING & GAS Itsi vet:TOk OVEN NOklHAIvrp1oN POOL HEATER API'H'OVED NOT lPPFOVED ROOM/SPACE HEATER .2*ROOF TOP UNIT I TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I`JNO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (., OTHER TYPE INDEMNITY 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 ,LI AGENT 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 beth of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia with all Pertinent pro ' 'on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME y � ,�� � LICENSE#'1/ SIGNATURE MP t/MGF JP JGF LP/ ��/ GI CORPORATION # PARTNERSHIP # L Cv# V..36C-- COMPANY NAME: e V 1C Q)t ..k iy3 ADDRESS / f ; Sd r-Lto c-' CITY /`!( Q. Z.Q.C._.. ._ ___.......,. ... J STATE MO—ZIP C:P Ot TEL �1�es..:3 _ ..,-7g'.._..�,_., FAX .... CELL KK'EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES /1/a' g,