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.- - -It, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY
Q17117 I 1 MA DATE 1 I .- I i3 I PERMIT N Q I`f—99 6
R JOBSITE ADDRESS (� I D (rSo{4 C orri S Un OWNERS NAME I,n[in i rl 6ih
GOWNER ADDRESS Ta60 K - 7257 .044b
TYPE
OCCUPANCY TYPE COMMERCIAL ��EDUCATIONAL❑ RESIDENTLAL
CLEARLY NEW.❑ RENOVATION:❑ REPLACEMENt:I„-,y. PLANS SUBMITTED: YES0 e
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APPLIANCES 1 FLOORS-, B94 $ 1 I 2 I 3 t 4 5 1 6 7 6 9 10 11 12 13 14
BOILER
BOOSTER ' 1 - !
CONVERSION BURNER +- I 1
COOK STOVE
DIRECT VENT HEATER
DRYER
FIRED ACE 1
FRYOLATOR �.
FURNACE
GENERATOR
GRILLE
INFRARED HEATER j
LABORATORY COCKS r
MAKEUP AIR UNIT
OVEN f
I :I
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
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— EDT. INSURANCE COVERAGE
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I have current aria ••; a its subdaltlal equivalent which meets the requirements ci MGL Ch. 16� i,..YES [X f NO Li
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I F YOU :- r;a ' a,PLEASE INDICATE TIE TYPE OF COVERAGE BY CHECKING TIE APPROPRIATE BOX BELOW
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LIABILITY INSURANCE POLICY IA OTHER TYPE INDEMNITY 0 BOND - t
OWNER'S INSURANCE WAIVER:I an aware that the licensee that mut the Insurance coverage rewind by Chapter 142"'CO 'C`
Massachusetts General Laws,and that my signature on this permit application wives this rquisrnnt 3
CHECK ONE ONLY: OWNER ❑ AGENT _
SIGNATURE OF OWNER OR AGENT
I hereby bendy Cat M d the detests at btaamatfon I teem rhrnttaed or acted negandIng this abdication are base and actuate b the best at my ImaMedpe
and mat ae p a,nlnO wok and k asaeaee pe honed wider the penult leausd for tile application we be in *$arkq Pa
Massachusetts State Plumbing Code and Chapter 142 r4 the General Lass. L`.C`)^'�NrorK Pwratm a the
PLUMBER-GASFITTERNAMEc-r¢112rrC\c NY\a`in cev.,VIgm LICENSE N ZctS SIGNATURE
-- '14,P MGF` JP J JGF❑ LGI❑ CORPORATION Ea iZ,`C' NL\ PARTNERSHIP❑a----- 1 LLC Jt� .
COMPANY NAMIE:;c3- fl Rtw.n\zun5SF,o‘ tcCS\h`ADORESS \ WeM nS-Ln �'A'
CITY 'L^\� \,rN STATE KcilSTATE 1 ]ZIP p256G>•, TEL IL{o‘ 63`1 `itCLAA_
FAX �CELL Lha G3'1`lbyl EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY Fr_NAL INSPECTON NOT S
\ Yes No
\ THIS APPUCATION SERVES AS THE PERMIT ❑ ❑
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'3• , FEE: $ PERMITS
PLAN N W N S
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