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• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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to CITY: 1;4[ ua v rim MA DATE: ,c7/S,j 3 PERMIT# He—/vf9
JOBSITE ADDRESS: (4 C{-m//4- 4 b OWNER'S NAME Term RAfres 01-1
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OWNER ADDRESS: -b,15-77 -c-r2 al 6 TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:ai REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES1 FLOOR–. Bsmt 1 2 3 I 4 5 6 7 8 9 10 11 12 13 14
BOILER �
BOOSTER
CONVERSION BURNER
COOK STOVE /
DIRECT VENT HEATER �
DRYER /
FIREPLACE
FRYOLATOR
FURNACE /
GENERATOR
GRILLE
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.142 YES.74110
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If you have checked YES please indicate the type of coverage by checking the appropriate box below. D� jDi
LIABILITY INSURANCE POLICY g OTHER TYPE INDEMNITY 0 BON J] MAY 15 Z45730-
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chater 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement UU• u. O DEPT
By
CHECK ONE ONLY: OWNER 0 AGENT 0
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 work and installations performed under the permit issued for this application will be wi all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: fr/ACTCQ wik-c LICENSE# 7S4Sr SIGNATURE
COMPANY NAME: oa p ti e2 Lo.f cc 0 ADDRESS: Fir AtseAir' in
CIN: F4 c-21 nat/' STATE: AAA ZIP: c9 ate,/ FAX:
TEL: CELL: re S 77( `/3 9 9 EMAIL:
MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
ROUGH GAS INSPECTION NOTES /, THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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F�D�� t � O/k' �`T- Vt/f Yes No P ✓lit cw O` / sz a
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
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FEE: $ PERMIT# l0/015h5
PLAN REVIEW NOTES
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