49-061 BP-202I-I 75.E
LENDALE RD COMMONWEALTH OF MASSACHUSETTS
ap:Block:Lot:
49-062-001 CITY OF NORTHAMPTON
Permit: New Build
4 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
i.o.
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-1754 PERMISSION IS HEREBY GRANTED TO:
Project# Contractor: License:
Est. Cost: 295000 103381
Const.Class: Exp. Date:08/01/2023
Use Group: Owner: MS HOMES LLC
Lot Size (sy.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 WORK:
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:
r
Rough p--22 y ough:,7—I f " .. "-I (louse# Foundation:
ijZ r7 Q v
s Finale. 6 Final: /o, (0_,a7- Final: Rough Frame), , '3-i&-zz 1C2
Gas: Z Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
„01C.K.. 3 5,.. 1L rc 1-2
Find: ► �— l'3 Final: Ic 1-ll•Z 3
i',, `� '>T� Gam_
THIS PERM MAY BE EVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF'
ANY OF ITS RULES AND REGULATIONS.
FI Signature:
I si 10
Fees Paid: $1,493.00
212 Main Street, Phone(-I11 - 7-1240,fax:(413)387-1272
)ffice of the »nnii sioner
ROAL - r AILPA
i. • r RS - R
-D . /}Ob ,
• Jo,sr wAgua. Mr��
�Y12AGZ00012 H 10 i3cr LOi406,
*� , The Commonwealth of Massachusetts
y t rl a= City of Northampton
of Occup
ancy
Certificate anc
fp y
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-2021-1754
Identify property address including street number, name, city or town and county
Located at
245 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 certify 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 he 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 Kevin Ross Date of Final Map/Plot: -
Building Official Inspection 01/11/2023
Signature of Municipal Date of
2023 49-062
Building Official Issuance 0112/ /
Home Energy Rating Certificate Rating Date: 2022-09-24
rinal Report Registry;D: 3o7844153
Ekotrope lD: zvwPMEV2
HERS® Index Score: Annual Savings Home:
245 Glendale St
Your home's HERS score is a relative
55Norperforma,ice scoce. the luwer the number,
thampton, MA 01062
the mare energy ec:ent the home.To Builder:
lea iciore, ;-it www.nersindex.com *Relative to ffi an average U.S.home
rn
MS Homes LLC
Your Home's Estimated Energy Use: This home meets or exceeds the
criteria of the following:
Use EIVIBtul Annual Cost
Heating 74.2 $801 2018 International Energy Conservation Code
Cooling 0.6 $27
Ho'Water 2.6 $107
Lig;,.s/Applia me; 27.6 $1,054
Lel vic:-. Cha,ges $96
Generation f,e.g.S.tar) 0.0 $0
Total* 105.0 $2,05
HERS Index Home Feature Summary: Rating Completed by:
dilt. Mar.I nelvy Home Type: Single family detached
Model: Colonial Ener jy ater Paul VellaTore
bo RESNET ID: 8 167Y2stmg 1.0 Community: ,lorthamptor.
Homes . ,.,„
COOd tiO led.too.Area: 3,912 ft2 !latin3,omp,..ny Energy ampliance Serv'ces
...rnbe.a.Bedroom: 3 27 Hudson Dr:Southwick MA 01077
1.......... ..
Refereme .„ Prim a.y Heatinv ..ystem: FLO.nace-1,opane 95 AT Uh. 43-427-242:
Home "'
.lo P f i mw y Coolin., 'System: Ai;Conditione,•Electric• .2.SEER Rating r rovide : Buildin:,Ef;icieac-y Resources
go P.irnar y Water Heating: Residential Water He..ster•Elect,ic-34 Energy FiLto. PO.3o(17,,9 3re ard NC 287 2
•••••••-•-os House TT:fitness: 11E1 GM50 i2,14ACH50; 8u0-399-9620
•,•••••lb ventilation: TX CFM•9 Watts
it. A.
so
D.ct I:eakage to uutsine: 39 CFM @ 25Pa(11 100 ft2)
Ao MIS HOPIt
so Above Grade Walls: R 21
-- - -
NI Ceiling: Attic,R-39 Pald DellaTh
Zero Energy Ale 10 Window Type: U-Value.0 29 SHGC:0 28
Home 0 Foundation Walls: R-13 Paul DellaTorre,Certified Energy Rater
Apr ...non Framed Floor N,A Digitally signed: 12/29/22 at 12:08 PM
v.,....,..,
1 ekot rope Ekotrope RATER Version:4.0.2.3060
The Energy Rating Disclosure for this home is as:dila:4e from the Approved Rating Provider.
I his report noes,KA constitute any Wd,63nty or gu(hantee.
Home Energy Rating Certificate Rating Date: 2022-09-24
Final Report Registry ID: 887844153
Ekotrope ID: zvwPMEV2
HERS® Index Score: Annual Savings Home:
245 Giendaie St
Your home's HERS score IS a relative
performance score. The lower the number, $ 1706
the more energy efficient the home.To Builder:
learn more, visit www.hersindex.corn *Relative to an average U.S.home Northampton, MA 01062
MS Homes LLC
Your Home's Estimated Energy Use: This home meets or exceeds the
criteria of the following:
Use EMBtul Annual Cost
Heating 63.1 $683 2018 International Energy Conservation Code
Cooling 0.7 $30
Hot Water 2,6 $107
Lights/Appliances 273 $1,043
Service Charges $96
Generation(e.g.Solar) 0.0 $0
Total: 93,8 $1,959
HERS'Index Home Feature Summary: Rating Completed by:
Home Type: Single family detached
- Model: Colonial Energy Rater: Paul DellaTorre
tso
Community: Northampton RESNET ID: 8776762
Extsting 144
Homes Iso Conditioned Floor Area: 3,912 le Rating Company: Energy Compliance Services
no Number of Bedrooms: 3 27 Hudson Dr.Southwick MA 01077
11,3'
Referem 0 , t Primary Heating System: Furnace•Propane•95 AT UE 413-427-2423
Home , IQ°
lo Primary Cooling System: Air Conditioner.Electric•13 SEER Rating Provider Building Efficiency Resources
go Primary Water Heating: Residential Water Heater•Electric•3.45 Energy Factor po Box 1769 Brevard,NC 28712
. 70 House Tightness: 1187 CFM50(2.14 ACH50) 800-399-9620 00'....
,
Ventilation: 70 CFM•9 Watts r,'
.5,
This Hoorio Duct Leakage to Outside: 39 CFM @ 25Pa(1/100 ft2) ,
_ i kw,l'oes m
Igi Above Grade Walls: R-21
IA Ceiling: Attic,R-39 Zero Energy
le Window Type: U-Value:0.29,SHGC:0.28 , ,
Home r:t Foundation Walls: R-13 Paul DellaTorre,Certified Energy Rater
-41.fr ut.VINO Framed Floor: N/A Digitally signed: 12/29/22 at 12:08 PM
t-IW ROW
111) ekotrope Ekotrope RATER-Version:4.02.3060
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 e erg)miciel.(Rs mod.-led)
245 Glendale St Northam.ton MA
HERS'Index Score: Rating Date: Sep 24,2022
55 HERS Regist D: 3v,844153
An-luat Estimates: Rating Co,npany:
Electric(kWh): 8,810.7 Energy Compliance Szrvicef
Propane{vall^n_}: Aggg Rating Provider.
Bu€iJing Efficiency Resources
CO'(Tons): 10 Rating Provider Address:
Approx.E•te-yy Cost: $1,959 PO Box 1769 Brevard,,NC
28712
HERS index Home Feature Summary:
Single family detached,3
bedrooms,3,912 ft2
uo
Exrsting ,sa rl.atirtg:95 A. ,E
Homes Lee
uo
Cooling.13 SEER
Hot Ware,:3.t5 E,tery Factor
Reference io6
Air t-ea.wge-
kg, t"' '167i-rhire(2.'4ACrl5C)
as
ro
Ventilation:IU CE M•3
JUCt Li-)
This►ram. 39 CFnn @ 2S?a(1 r 1 u0 ft2)
m Auove Grade Wa Is:R-21
,o
so Ceiling Attic,N-39
Ieco E
Window:U:0.29•SHGC:0.28
IMO WNW r'"e"" Foundation Walls:R-13
t 1.tie ine RA1't R Version'
ekotrope 4.0.23060
This resxotckw,rift o Riots,.w worm-Ay o 9 era wee.-.
IECC 2018 Performance Compliance
Property Organization Inspection Status
245 Glendale St Energy Compliance Servic 2022-09-24
Northampton, MA01062 Paul DellaTorre Rater ID (RTIN): 8776762
Model: Colonial RESNET Registered
Community: Northampton Builder (Confirmed)
MS Homes LLC
0218 Sergey Savonin_245
Glendale Rd_Northampton
0218_Sergey Savonin245
Glendale Rd_Northampton_221229
Annual Energy Cost
Design IECC 2018 Performance As Designed
Heating $2,487 $2,504
Cooling $99 $87
Water Lleatinc $119 $119
Mechanical Ventilation $64 $12
SubTotal - Used to determine compliance $2,769 $2,721
Lights &Appliances w/out Ventilation $1,148 $1,148
Onsite generation $0 $0
Total $3,918 $3,870
R405.3 Source Energy Exception: The proposed home uses 4.19 MBtu LESS source energy than the r:ference home.
Requirements
a R405 3 Performance-based compliance passes by 4 The proposed house meets the IECC 2016 Peno-m mce r e-ence e.,ergy bit
requ rement by Ii4ty C3(4 19...Eto).
a R402.4 .2 Air Leakage Testing Air sealing is 2.14 ACH at 50 Pa. It must not exceed 3,00 H at 50 Pa.
la R402.5 Area-weighted average fenestration SHGC Area :relighted average fenestration SHGC is 0 2C,The rn ximurn allowed value is
[No Limit].
• R402.5 Area-weighted average fenestration U-Factor
a R404.1 Lighting Equipment At least 90 0%of fixtures shall be high-efficacy lamps.cur -ntly 100 0%are high-
efficacy.
• R403 6.1 Mechanical Ventilation Efficacy
Mandatory code mquirements that are not
Mandatory Checklist checked by Ekotrope must be met 2018 IECC Mandatory Checklist must be checked as corn,lete.
• IRC M1505 4 3 Mechanical Ventilation Rate
GR405.2 Duct Insulation All ducts outside the thermal envelope must be insulated ti at least R6.0.
Design exceeds requirements for IECC 2018 Performance compliance iy 4.2%.
As a 3rd party extension of the code jurisdiction utilizing these reports,I certify that this energy code compliance document has been created in accorda e with the requirements of
Chapter 4 of the adopted International Energy Conservation Code based on HAMPSHIRE County If rating is Projected.I certify that the building design d-scribed herein is consistent
with the building plans specifications, and other calc,$ations sub Med with the permit application If rating is Confirmed, I certify that the address eferenced above has been
inspectedlested arid that the mandatory provisions of the ItCC hare been installed to meet or exceed the intent of the IECC or will t e verified as such b another party.
Name: Paul DellaTorre Signature: ,
e .47-6)te
Organization: Energy Compliance Services Digitally signed: 12/29/22 at 2:08 PM
Ekotrope RATER-Version 4.0.2.3060
IECC 2018 Performarce co pine results,.alculated ustng Ekotrope RATER's energy :t.r1 code>c,mpl,t,ice algort:e.
Ekcsrope RAt ER is a RESNE A.cre.ited rrERS Rati-g tool results 3re b_sed on data entered t y Exottope wits
tkotrope disdain-Is all.iabdity for the intormaton shown cn this report
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... Northampton, MA 01062 . .-
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,... , )• THIS HOME IS CERTIFIED TO MEET THE
,.. ....
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:.: . 2018 INTERNATIONAL ENERGY CONSERVATION CODE -...
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Ceiling i\nic. R-39 Dust Supply R-4.0, Return R-0.0
.._
.... ..,
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,.- Above Grade Walls R-21 Duct Leakage to Outside 39 CFM @ 25Pa (1 /100 ft2)
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,.. . Foundation Walls R-13 rotal Duct Leakage 157 CFM @ 25Pa(Post-Construction) .-.
.4,,„•
Framed Floor NIA Heating Furnace•Propane•95 AFUE
Slab R-0.0 Perimeter, R-0.0 Under Cooling Air Conditioner•Electric- 13 SEER --'
... --.4.7.: '0, ( •:Zir
... Infiltration 1187 CFM50(2.14 ACH50) Water Heating Residential Water Heater• Electric • 3.45 Energy ...
,.. ...
,.. Factor , ...,
Window U-Value: 0.29, SHGC: 0.28 .,...
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--- 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 •..t
:.'
Chapter 4 of the adopted International Energy Conservation Code based on HAMPSHIRE County It rating is 'rojected I certify that the building design described herein is consistent with
•-- the building plans,specincations,and other calculations submitted with the permit application.If rating is Confirmed,I certify that the address referenced above has been inspected/tested
. ...--•
and that the mandatory provisions of the IECC have been installed to meet or exceed the intent of the IECC or will be yenned as such by another party.
4;;
... .-.
-•- • -.'
Name: Paul DellaTorre Signature: Paid DettaTeue
:.: ...
. .
....: Organization: Energy Compliance Services Digitally signed: 12/29/22 at 12:08 PM
....,
Ekotrope RATER-Version 4.0.2.3060... :_018 IECC compliance res.ilts calculated using Ekotrope RAT ER's energy an....code compliance algorithm
Ekotrope RATER Is a REbNET Accredited HER,Rating Tool At yes'Its are baser on data entered by Ekotrope users
Ekotrope disclaims all lial.ility for the information sno,idi on this report
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IECC 2018 Label
245 Glendale St
Model: Colonial
Ekotrope RATER-Version: 4.0.2.3060
HERS®Index Score: 55
Ceiling: R-39
Above Grade Walls: R-21
Foundation Walls: R-13
Exposed Floor: N/A
Slab: R-0
Infiltration: 1187 CFM50 (2.14 ACH50)
Duct Insulation: Supply: R'., Return: 110
Duct Lk to Cutdc ors: 39 ;;FM (r 25Pa (1 / 100 ft2)
WindowWiodoW,&Door Sys_._
U-Value: 0.29, SHGC: 0.28
Door: R-6
Heating: Furnace• Propane •95 AFUE
Cooling:Air Conditioner• Electric• 13 SEER
Hot Water: Residential Water Heater• Electric•
3.45 Energy Factor
Average Mechanical Ventilation: 70 CFM
Signature:
y'ei A 4---o 71- 76. (-,"
-- $2351- G� 3
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=i• CITYITOW 1 O< i_G:i/�'I�ICi/\ PERMIT MP, DATE �r ERM T 201,2—OO 3 2,
JOBSITE ADDRESS � /S 7e.od iP 011-OG�.-oo/,OWNER'S NAME �( •c IO1
rn
P ( OWNER ADDRESS TEL �3�7 � 6 F
fV
fV
TYPE OR I OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 8'
PRINT ;�;/
CLEARLY I NEW:L/ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR-0 I BSna ! 1 I 2 I 3 14 15 16 I 7 I 8 I 9 1 10 I 11 I 12 I 13 114
j BATHTUB ( 1
CROSS CONNECTION DEVICE I I I I I I I
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
I FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /' PLUMBING & GAS INSPECTOR
LAVATORY '/ N O RTH AM PTO N
ROOF DRAIN APPROVED NOT APPROVED
SHOWER STALL
SERVICE/MOP SINK A 16 ,
TOILET 3
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING f
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES,Er NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF 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 ❑ 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 best of my knowledge I
and that all plumbing work and installations performed under the permit issued for this application will be in corn liance with. II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter
14,2 of the General Laws.
PLUMBER'S NAME " y j4U l//U 2 r4 d LICENSE#/��J j(� SIGNATURE
( MP❑ JP El CORPORATION Q# PARTNERSHIP❑# LLC[# 3gcc
I COMPANY NAME / IIJM(eel/ 1/4/n 1! ADDRESS /ems s�2 7�e>��/C7i id
CITY r l �'(.0/')-C�V STATE A A ZIP QO a TEL
v
FAX CELL EMAIL
i 1
?2-7 Q/
?1t/ 22 ,fz <J/
(/ J e61 L - 6
C=64-J#/Ooc.i-D s
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING ING WORK
CITY Northampton J MA DATE 03/18/22 I PERMIT#e,;17-2o 2Z-0 I #S
JOBSITE ADDRESS 245 Glendale Road OWNER'S NAME MS Homes LLC
G ,OWNER ADDRESS 231 W School Street,W Springfield MA 01089 I TEL413-244-0336 IFAX 1
TYPE OR Q OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ® RESIDENTIAL Q
PRINT a
CLEARLY NEW:j RENOVATION:Q REPLACEMENT:0 PLANS SUBMITTED: YES El NO0
APPLIANCES 1 FLOORS--• BSM 1 2 3 4 5 6 7 8 9 10 1 12 13 14
BOILER _( '
BOOSTER 1.�__ i I I
CONVERSION BURNER
COOK STOVE . .
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATORin ineeign
GRILLE
INFRARED HEATER
MAKEUP AIR UNIT
l{iP
• 'IiNAI
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST IIIIIIIIiI_I I
UNIT HEATER 411.111111111111.111111111.11111W1111111.111111111111111111111IFINIMINIFIIIIII
UNVENTED ROOM HEATER
WATER HEATER MI M MI 11111111111111111 NMI NE INNISh
OTHER UG Line 1
..e
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY Ej 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 ED 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 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. f c
PLUMBER-GASFITTER NAME Stephen Constantine LICENSE# 3063 I ,!J SIGNATURE
MP ED MGF Q JP U JGF® LPG!0 CORPORATION Q# MM. PARTNERSHIP®#[]LLC�#
COMPANY NAME:Osterman Propane LLC ADDRESS 339 Amherst Road
CITY Sunderland STATE AM ZIP 01375 ITEL 413-549-1000
FAX N/A I 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#
PLAN REVIEW NOTES 9
LS--/i-ZZ OAes3crt-n A20 6�S
N a re-sr e.d-A71 ernv j
_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,aim
i= CITY N es(` (vI ip'-G-r. MA DATE 6f7,3 .`.2 PERMIT# 64:4"AZ •Q 72
JOBSITE ADDRESS y 5'- 6 ..! (C,O1_ OWNER'S NAME C 1' U ,[ c
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL i
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
l
APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _
BOOSTER
CONVERSION BURNER
COOK STOVE
'
DIRECT VENT HEATER ' I ' '
DRYER
FIREPLACE
FRYOLATOR 1'C
FURNACE
GENERATOR f
GRILLE
INFRARED HEATER �.,.
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER Pl UMf3NG & GAS INSPECTOR
ROOF TOP UNIT NORTH fir"PION
TEST PROVED NCDT AWYF OVER
UNIT HEATER
UNVENTED ROOM HEATER
f WATER HEATER
OTHER
INSUNCE
VE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES RAGE
VN O
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1-"---- OTHER TYPE INDEMNITY BOND 1
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 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 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 /�f //t/f AVi & LICENSE# / 6 SIGNATURE
MP _.LMGF JP JGF ,-/LPGI CORPORATION # PARTNERSHIP # /- LI1lC1 Y3ES'
COMPANY NAME: lick4- !.,.. ' ADDRESS /.�S—� � � /,. .., .
CITY / "l d• 45,,,CL,%3,2_erig,_, STATE ti ZIP �'��`1 ?lr._
FAX TEL / ��2 F���CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
/ _70-—22 freZ 13' 7 ' 77 PLAN REVIEW NOTES
O- 6- -40- F.; i c rr,
Afe
/-/c,