BLDG-19-001438 •
, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1 _ YmYmOU1 t , 5 9
CITY hM DATE ( a� PERMITSnG i6 " ISr7
JOBSITE ADDRESS 21 'll r rLi 1 Q1Inc\ S- OWNERS NAME Reim.% S h o,�
OWNER ADDRESS SOovrit TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL tgl
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS-' ESM 1 2 3 4 5 6 7 8 9 10 11 12 1314—
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
1
FRY OLATOR
FURNACE
GENERATOR M
GRILLE
INFRARED HEATER
LABORATORY COCKS _ R,ECELVED
MAKEUP AIR UNIT
OVEN
POOL HEATER • She - 7 zata- -
ROOM(SPACE HEATER
ROOF TOP UNIT Bu L r� fr r
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TEST' .. . .. _. ._ . .... . _ . . . ._ ...._ _. T
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 2 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY g 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
J 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 accurat-�Jr e best of my kn. g-
and that all plumbing work and Installations performed under the permit Issued for this application will be in compll ionioozvia. r�e
,� Massachusetts State Plumbing Code and Chapter 142 of the General Laws. allie
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PLUMBER-GASFITTER NAME LICENSE ft /Z IGNATU '
NIP IR PAGE❑ /BJP❑' JGF 0 LPGI10 CORPORATION' ft 33bs PARTNERSHIP 0 If s C❑f
COMPANY NAME F\ .s.t-\ . tUn(-4 V1 •tot\ lit- ADDRESS RI)& R 1 o5-c f v7 )4A 1J-6t"-i
CITY I�Y�"i '� i JAN* STATE�'1CA ZIP 0261) TEL/( ' 27 967'7
FAX CELL SCA ' EMAIL s. u u 1 CA 0 SP u.�. ) 0
4 5 0
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
/„ OX THIS APPLICATION SERVES AS THE PERMIT 0 0 °1
/�
7 /71
FEE: $ FLAN REVIEW NOTES !/ G 1(1/1/e