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S=3. MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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- IOWN 'SNAME •/`•1•/� �. f[L/
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL J RESIDENTIAL
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NEW:LI RENOVATION:1 REPLACEMENT:,_I PLANS SUBMITED: YESJ NOTE
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _—I LJ__J_!___I___1— •
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BOOSTER _J___I__J_I L JLL _`_F_i__Li.J___f.4LJ_I
CONVERSION BURNER • I_�.-J_�—UJJ. JLLJJLJ J,__i;__I._J._I
COOK STOVE
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FIREPLACE U .J__LI_JCL:.__"._
DIRECT VENT HEATER — I
DRYER•
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JFRYOLATOR ---1- . k. -a. ...._ I,._.. J _mf-J._._1—.1_1
FURNACE —J-J•—J_1_I'__J'�. ____1•___I_I
I GENERATOR —1_-I !
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GRILLE _3_f ; (._JJ._--I_!_j,_J_J_J_-J_Li_-1_J
INFRARED HEATER _—J J _I= L�' ___.I___I_J'-_J'^J_I
LABORATORY COCKS —J_�-_j_ __J�J _1_J_J_1_J_1
C MAKEUP AIR UNIT "_7 f_J I _J ' I • I
OVEN —L1__ _ t_—J_I fJ_-1_.J�I_1_.I_I__i—_I__J_1.
POOL HEATER
ROOM I SPACE HEATER _II L - I `_I^J I,3_j_I, I :- -,I - --j-
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TEST TOP UNIT �I_./_1—J—J—I —_I—J • `--I- �I_-1
UNIT HEATER —J --f 7f
UNVENTED ROOM HEATER 'i I_1_,I_ 7tIIJ r cJ ' i-�
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INSURANCE COVERAGE
te I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES g NO
qe IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ' BOND Ej
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 AGENT ;:.I
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 all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME i Ir'�t C e r_�I LW n r&O TI UCENSE# �/l SIIGNANATURE
MP 0 MGF'1 JP 53- JGF J LPG!;,J CORPORATION`i#r -61 p7 PARTNERSHIP #� 1 LLC 7,11/1-7
COMPANY NAME' V —i T ADDRESS- -UGI,fsci r (ADZ„/ r-tE; � --- -
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CITY S r9 J R L c( r M ✓O, t 1 STATE. ,ZIP• ITEL -) .7 $r D '/7-1
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY /NAL INSPECTION NOTES
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THIS APPLICATION SERVES AS THE PERMIT 0 0 F/f>, y(-- _ o &-3
FEE: $ PERMIT
FLAN REVIEW NOTES ,
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