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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
CI MA DATE: PERMIT
JOBSITEADDRESS ` OWNER'SN E
OWNER ADDRESS, TEL: FAX:
OCCUPANCYTYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑
APPLIANCES? FL OR-- Bsmt 1—j 2 1 3 1 4 1 5 8 1 7 8 9 1 10 11 12 13 14
BOILER 1 1 1 1 1
BOOSTER I
CONVERSION BURNER 1 1 1 I I
COOKSTOVE 1 I I I
DIRECT VENT HEATER I I I I I
DRYER
FIREPLACE I
FRYOLATOR I I
FURNACE 1 1
GENERATOR I
GRILLE 1 I I I
INFRARED HEATER 1
LABORATORY COCK 1 I
MAKEUP AIR UNIT
OVEN
POOL HEATER ni 15 h,5
ROOM/SPACE HEATER
ROOF TOP UNIT I
TEST Ju
100L. f
UNIT HEATER I
UNVENTED ROOM HEATER JBVI4GDE IT
WATER HEATER I Y
INSURANCE COVERAGE
I have a current liabilityinsurance policy or its substantial equivalentwhich meets the requirements of MGL Ch, 142 YES ❑ NO ❑
If you have checked YE •5 please indicate the type of coverage b checking the appropriate box below.
LIABILITY INSURANCE POUCY [j]OTHER TYPE INDEMNITY ❑ BOND ❑
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 ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted (or entered) regarding this application are tine and
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in i
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. +Z/
COMPANYD
CITY
TEL: _
MASTER ❑
STATE: `' / ZIP:
GEL`�l��i �YEMAIL:_
JOURNEYMANfLP INSTALLER ❑ CORPORATION ❑ a PARTNERSHIP ❑ LLC ❑
FAX
best of my
ROUGH CAS INSPECTION NOTES I THIS PAGE FOR TNSPECFOIt USE ONLY I FINAL INSPECFI ON NOTES
Yes No
THIS APPLICATION SERVES ASTNEPERMIT ❑ ❑
FEE: E PERMIT &
PLAN UEVIEW NOTES