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MASSACHUSETTSreaUNIFORM APPLICATION FOR A ERMIT TO PERFORM GAS FITTING RK
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{,, MA DATE PERMIT# /*G?Gu t
e'��� CITY �Q .1/4�� (�tJ r"� �� �2 n,� / 9
JOBSITE ADDRESS ?Q 3 C', lye 5'he"n/2� 7), OWNER'S NAME ante-/ i 29 L 4 /L
GOWNER ADDRESS C 5--eS<)TEL ei ,e7—/,2 a' FAX
TYPEYT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRICLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO p
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 f 12 13 14
BOILER �CnAli, D /
BOOSTER
CONVERSION BURNER —
COOK STOVE
DIRECT VENT HEATER _
DRYER _
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR RECEIVEu±
GRILLE _
INFRARED HEATER
LABORATORY COCKS I. NV)G 13 Zat3 IF
MAKEUP AIR UNIT _
OVEN BUILD NG D1PAR-MEN I
POOL HEATER jr --I--- t
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST ...... _- ---
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER /r a M 6/ / _
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IA NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 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 ell Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.vii \
PLUMBER-GASFITTERNAME�IGbr/* ,9, f Ge LICENSE# no . r (SIGNATURE
MP 0 MGF 0 JP®. JGF 0 LPGI 0 , -%RCP RATION # PARTNERSHIP 0# LLC❑#
COMPANY NAME /14 CIS(jr 19714 ADDRESS 4' £J5"C• "gni cy t�
CITY vJ for p riQr/� STATE ZIP TEL 77 V Z/0 S/ Z
FAX CELL EMAIL a n i.
G0aI8011 4 &'D
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No { y
THIS APPLICATION SERVES AS THE PERMIT 0 0 -z 4f or
FEE: $ PERMIT if L, A SO,v
KLAN REVIEW NOTES
1