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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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MA DATE / PERMIT#j v-��/7'a'�D�(/
JOBSITE ADDRESS! P 0 570 /vy frit AI OWNER'S NAME ///4 t)fe'1 '5
GOWNER ADDRESS 6 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 11
PRINT �/
CLEARLY NEW:0 RENOVATION: L� REPLACEMENT:❑ PLANS SUBMITTED: YES❑ N0.12
APPLIANCES-1 FLOORS-0 SSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE J
DIRECT VENT HEATER
DRYER
FIREPLACE `
FRYOLATOR
FURNACE /
GENERATOR
GRILLE /
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER _
ROOF TOP UNIT
TEST F
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER f
OTHER
INSURANCE COVERAGE J
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I Si 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 th all P ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of General Laws. (,p �`
PLUME R-GASFITTER NAME6 9 ex; LICENSE#88,t �� SI ATURE
MP�MGF❑ JP❑ JGF
D.2PGI❑ CORPORATION❑/# PARTNERSHIP
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COMPANY NAME&I �L 7'c2 L�� /4l�I�(/f4.DDRESS/Q ‘740/11 l -C-
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CITY I� rate &4. STATE 0 �LI� ZIPS i 6 yam ` � ; 7,
FAX CELL EMAIL III 08 2016
BBUIetlNCy EPA RTIJE NT j i P //
ROUGH GAS INSPEo'ION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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Yes No /f-4-/446 044 CJ'C /o/N7
THIS APPLICATION SERVES AS THE PERMIT 0 0
PEE: $ PERMIT#
PLAN REVIEW NOTES
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