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11/18/99�U 16:05 FAX 617 727 2197. S
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BOARD OF STATE EXAMINERS OF PLUMBS S r
239 Causeway Street D Boston, Mass i � � sF1
617-727-9952
Fuimb available at http://www.ototo.ma.ue/reg/boards/pl/forms.htm
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1000
Application for tievacea Gas rressurc Rrvicn
Must submit $50 each application -Make che,Ck payableLUCA
Comm. of MA
role Tncpprtnr fnr the C itv of J 1/ � r -�1 �
Company/ Nam. y t �r (,L'^�I �) '-JA 7/ P ! i ✓'� rJ _'NC ,
Street/City/Zip 1 W vt-'j C _
Signature/Title 9065. Telephone �.3 J �?'�
on this date: 'DO has requested an elevated gas pressure system at: 13yo 0kS Sc 00 C
1160 – i- ect—jo4 'j J o U 0y)
for the follow' g reason(s). c i rc r�r�?_ .,! fr N�
STV 1/0
The manufacturer certifies that the equipment described here: C ro 0 rl .
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COCK � J 1 der dccs C_
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� rN rhoaM� 1121 AI'l, eQA J J0�CoC 64Se e, t3uiU'v.
has a gas input rating of ft. 3/hr. and requires a gas pressure of (inches/lbs.) Low pressure
n for total connected load of ft, 3/hr. requires an IPS
installation design I/��Meof
Elevated gas pressure of (inches/lbs.) will allow for an IPS pipe size of F
Please submit total developed or equivalent length of piping to the most remote area with this application.
NOTE: Piping Plans Stamped By A Mass P.E. Must Be Submitted With This Application.
The serving gas supplier,
represented by (Signature
on this date 26 ao,
ft. 3/hr. . at the outlet of the meter set assembly:
PLEASE NAIL APPROVAL TO:
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The variance request from the Massachusetts Fuel Gas Code, Article 1.1. La.3. (as amended) is hereby granted/dom ed for
elevated gas pressure of (its/lbs.) Any additions or alterations to the system are not permissible
without the prior written approval of the State Board of Examiners of Plumbers and Gasfitters.
A completed copy of this variance request shall be filed by the applicant with the local gas inspector before the start of an
work. .
Date:
Executive Sec tary for the Board elevgas
1 >
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
Type or print) Date '— ( 19 U
NORTH ANDOVER, MASSACHUSETTS ,� 1
Building Locations
Owner's Name
New Renovation F-1Replacement ❑
45 ro c e'
Plans Submitted ❑
Permit #
Amount S
()O
(Print or type) t C�Colp—
Address
eck o Certificate Installing Company
Name
❑ Partner.
Business Telephone ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked ves, please indicate the type coverage by checking the appropriate box.
Liability insurance policy❑ Other type of indemnity F-1Other❑
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 1=12 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
of Owner or Owner's Ayent
Check one:
Owner ❑ Agent ❑
i hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued For this application will be in
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By:
Title
C iry/Town
APPROVED (OFFICE; USE ON(. v)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber
❑ Gas Fitter License Numoer
j Master
S❑l Journeyman