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" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
P"3tilt"t ' CITY 44 frd'r7G/i/ L' MA DATE /l/J(%e PERMIT#ofnb-n706
JOBSITE ADDRESS 3/2L!/ij7sae,./ }-6271% GQ,el^ OWNERS NAME MA. X.00OWNER ADDRESS / ^TEL$? —?O7 -F6 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT
CLEARLY NEW❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS—. End 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER _
CONVERSION BURNER,
—
COOK STOVE 1'
DIRECT VENT HEATER •
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT i rE _
OVEN `rr a
,
POOL HEATER I I rl I i
ROOM I SPACE HEATER
ROOF TOP UNIT
Hun c
TEST o... -
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE r-�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES lJ N0 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TFIE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY Ia/ OTHER TYPE INDEMNITY 0 BOND 0
• OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the •
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
•
• CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c iliance with all Pertinent of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. K.)6711,---
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PLUMBER-GASFITTER NAME Darr'en
eachK LICENSE 2.3I7�o � SIGNATURE
MP ❑ MGF❑ JP❑ JGF[' LPGI❑ CORPORATION�/ 0 4 PARTNERSHIP❑# LLC❑#
COMPANY NAME !e• In /GD e. Plcoibii {L�/,6,_j - ADDRESS 70 Ace Ey A<CITY /t�Brciion /72.7//5 E!`//l$ STAT € 21P Qcy?' • TELL?�20 -dolt_FAX CELL EMAIL De• C nOOK PNER3 /like rr`�CO/� �. '.
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
I agar THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT 8
lam« S ?LAN REVIEW NOTES
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