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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: / /77ooni- MA. DATE 6/A1Z//•2- PERMIT 417.-r
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JOBSITE ADDRESS:/0 am 6 /04-4145--3 /04-4145- rOWNER'SNAME4 Y 124'///fl/cicc/,1/4to
GOWNER ADDRESS: /5.--tur1L/wff r 04A1410 EL: n-art'trV7FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL®"
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:®' PLANS SUBMITTED: YES 0 NO.CSI
APPLIANCES) FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTERV F
CONVERSION BURNER
COOK STOVE
DIRECT DRYER VENT HEATER JUN 25
1012•
FIREPLACE
FRYOLATOR BU LDING DEPART T
FURNACE Uy
GENERATOR er,K A 3 /6
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.1429�'VS. 'NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below. 64e te' `c
UABILITY INSURANCE POUCY }" OTHER TYPE INDEMNITY ❑ BOND ■ •' 4
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 o
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
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 wort and installations performed under the permit issued for this application will be in lian a went
provision of the Massachusetts State Plumbing Code and Chapter Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: 44011 P /5-.0 LICENSE k SIGNATURE
j COMPANY NAME: HM'// P11k ZWC ADDRESS: 997 O!-/l C ,@D.
1 CITY: Soo,* 1///11•entirS STATE: /h/1 ZIP: orgG6O FAX: COP" 'gn=6064y__
TEL: 501-315--9/Z-7 DELL Ewa:,Wif0.0#4z t Qa&7 24>r/ .ivsr
MASTER Nr JOURNEYMAN 0 LP INSTALLER❑ CORPORATION 02eo PARTNERSHIP 0= LLC_i
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