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„ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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WWe CITY r JAYt..kpt)c� �br-� MA DATE S-- 2%IL2 PERMITiI/�'-s'6-/g-(06TV/
JOBSITE ADDRESS P79 evk c0..-.01 � t..'E OWNER'S NAME Fri u
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL'®'
PRENT
CLEARLY
h' NE'W:❑ RENOVATION2 REPLACEMENT: ❑ PLANS SUBMITTED:YES❑ NO 0 •
APPLIANCES 2 FLOORS-{ SSM 1 I 2 3 4 5 6 7 3 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER Ci E % V t
DRYER K E •
FIREPLACE
FRYDLATOR MpY Ly L)t° A all
FURNACE i1
GENERATOR ,rte' rEgg-, 1-
GRILLE
GRILLE
INFRARED HEATER ""'—
LABORATORY COCKS 1� (fie .
MAKEUP AIR UNIT7t eV
OVEN _ f
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT _
TEST . . —
UNIT HEATER
INVENTED 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 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGES?CHECKING THE APPROPRIATE BOX EELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 0 AGENT 0
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 provis' n of the
Li) Massachusetts State Plumbing Code and Chapter 142 of the
General Laws. - -
PLUMBER-GASFITTER NAME Th—&o\cA pwr"c-A LICENSE# I33g9 SIGNATURE
MP . MGF❑ JP\\❑ JGF❑ LPGI❑ CORPORATION❑ti PARTNERSHIP❑1t LLC❑ft
COMPANY NAME ivr5 1`eC�..uo\oaC► ADDRESS R `tea WwC4V S WCnt�
CITY 0/%4
W t 12 STATE v''A ZIP D 3-56 3 TEL Stu - er —gaGy
FAX CELL EMAIL 1T11--eCt-N. Fs)S C. W3/4-CA -. eCA✓�
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ROUGH GAS INSPECTION NOTES THIS, PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑ ra y
FEE: $ PERMIT# q ,}
PLAN REVIEW NOTES
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