G-13-1016 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t�' CITY r _/rtectuu7f/ MA DATE JS/5- /,j J.PERMIT# b/3 rid/tl�
JOBSITE ADDRESS /60 +` Lz Pee. J OWNER'S NAME !sed 6es LaP
OWNER ADDRESS 7 `lf.„,3!td „ N..QZ{(G TEL �A� .2 -tt1I1�CI. F � /
TYPE OR OCCUPANCY TYPE COMMERCIAL-1 EDUCATIONAL Li
PRINT RESIDENTIAL,` r� "M, t/wJ•4
CLEARLY NEW:[„! RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES , NO S
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER zits
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE C� f ft.
FRYOLATOR
FURNACE :
GENERATOR MAY 1 J 20'3 -'
GRILLE
INFRARED HEATER LD.w rw Gtr t
LABORATORY COCKS Cy
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER ,
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES VNO
NO ( F
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ! OTHER TYPE INDEMNITY LI BOND f,„„,
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 c.1 AGENT ;71
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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NAME .7;1(.41. z!5' J LICENSE#V` „V?~~ z SIGNATURE
MPS MGFL, JP L( JGFD LPGILi CORPORATION;✓#;345.3IPARTNERSHIP 1:1# LLC„_.#j„„„„„„
COMPANY NAME r„, T,4E ,.,.qd
/Z4 . ADDRESS! S � sl iii) cS J
CITY neem 9” . .......-,.. _ G STATE .JZIPi /gS,S,1TEL
FAX. _,_.4CELLM m.,,._.. !EMAIL
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