BLDG-19-002066 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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r CITY �� v 1 4 MA DATE 6'�!�/ PERMIT#/fi /J'/!-aa0d4
s JOBSITEADDRESS a 1 ISloI 5/ 6` OWNER'S NAME /90/Nu 54e/A
OWNER ADDRESS CUi 5/04 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[3
PRINT
CLEARLY IJE'W:d RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO p'
APPLIANCES 7 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE •
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DIRECT VENT HEATER —
DRYER _
FIREPLACE _~
FRYOLATOR
FURNACE
GENERATOR
GRILLE —
INFRARED HEATER
LABORATORY COCKS .
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MAKEUP AIR UNIT
OVEN 1E -GE nth L:1
POOL HEATER •
ROOM I SPACE HEATER T j
ROOF TOP UNIT
2413
TEST _.
• UNIT HEATER eui�Ga�pr•
LINVENTED ROOM HEATER
w =^r Y �f --
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [l NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 12/ OTHER TYPE INDEMNITY 0 BOND 0
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 ❑
SIGNATURE OF OWNER OR AGENT
tb 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
`3- and that all plumbing work and installations performed under the permit issued for this application will be In complian all Pertinent provision of the
LI) Massachusetts State Plumbing Code and Chapter�14 f the General Laws.
PLUMB R-GASFITTER NAME v 1y '"4"GS LICENSE eSfo SIGNATURE
MP MGF❑ JP 0 JGF 0 LPGI, GI0 CORPORATION❑# PARTNERSHIP/ / ❑# LLC
COMPANY NAME 6Qt/ oa��/i!0 /I G ADDRESS/O/l !thiel/ h
CITW'V' Vebi- wz$ STATE�iI ZIP Uo2(�77 TEL 5-0 jo,c*,af
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No b/'& C—`
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ���
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FEE: $ PERMIT II A P� (// `/(f��-�'-)
PLAN REVIEW NOTES �%/
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