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‘,..;-•>.._. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -
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` yg4 ry CITY "lA.f �o J MA DATE 1^it-Z(3 LF PERMIT# / /J(r n-90/85r
JOBSITE ADDRESS UI ar cest-y Pr ack OWNER'S NAME Ski 4- (IT
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALM'
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YESCK NO❑r
APPLIANCES 7 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
DRYER [. -
FIREPLACE _
FRYOLATOR
FURNACE -
GENERATOR -
GRILLE -
INFRARED HEATER
LABORATORY COCKS : 1._pI
MAKEUP AIR UNIT
OVEN
POOL HEATER SEP t 1 ,
ROOM I SPACE HEATER
ROOFTOPUNIT BUIL' . i '•.A ,. ..1,Jr
TEST ___ _
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER T--
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 40 0
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I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE, BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY VC.,, 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 D
- SIGNATURE OF OWNER OR AGENT
7.1„+ 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
'S- and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with all rtinent provision of the
�J Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFIT IER NAME Shit,v ‘44,-)ra .-r- LICENSE# 1 C&22 SIGNATURE
MP MGF 0 JPP0 JGF- 1❑ LPGI 0 CORPORATION❑41 n PARTNERSHIP 0# LLC❑#
COMPANY NAME 14.4.n1a..- P41-P ADDRESS 06 QO`rc °et
CITY C fl f G('✓C(LC- STATE( * ZIP 02p 152. TEL en�23 'OZ,�/ e
FAX CELL EMAIL hCA p(uembMy/1M2)tccIAA
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ r T.QNYL 046 �jOA
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FEE: $ PERMIT H �/0 f'- ///79//3"
PLAN
PLAN REVIEW NOTES
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