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� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS
/FITTING
�WORK
k -,� CITY Yeref- i I MA DATE r2J PERMIT# C��i7 —9TTCY
JOBSITE ADDRESS C1,a1'q ayy]______ I OWNER'S NAME C a __l
GOWNER ADDRESS l O 2a'S Way TEI� � t•CL,T FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E] 7 EDUCATIONAL❑ RESIDENTIAL '
PRINT'
CLEARLY 'NEW:❑ RENOVATION:LI REPLACEMENT: PLANS SUBMITTED: YES N0 '
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 `10 11 12 13 14
BOILER vI i
BOOSTER
,
. CONVERSION BURNER a
COOK STOVE .+ a -
DIRECT VENT HEATER + 'I 11 1
DRYER _-
FIREPLACE 4
FRYOLATOR I ' '+
FURNACE -_ —:I— .
GENERATOR e r,
GRILLE
INFRARED HEATER %. . I
LABORATORY COCKS
MAKEUP AIR UNIT c i +1
OVEN
: II 1, A �� .1
POOL HEATER -- �. t v
r
' ROOM/SPACE HEATER
ROOF TOP UNIT 1 -
-:i c
TEST
t
UNIT HEATER '
UNVENTED ROOM HEATER
WATER HEATER
OTHER ,. — ,I - i
.i-_ �
1 ` it .1 J
INSURANCE COVERAGE �
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ❑NO!'
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 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 Gen- .ws,and that my signature on this permit application waives this requirement
ill... CHECK ONE ONLY: OWNER>4 AGENT 0
NA' ¢ bF'OWNERORAGENT
' I hereby certify that all of the detai s - • - - -• 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 complia,c- with all Perti - t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME S[/.C2s_j (LICENSE#I nFr SIGNATURE .
MP 0 MGF❑ JP/24JGF❑ LPG(❑ CORPORATION❑# PARTNERSHIP 0/4 LLC #
e3( ADDRESS a7
COMPANY NAME: /eye. I / �, 1 I'K�l�, r�--
CITY r, JT''�'" I STATE RAJ ZIP ..JTELFar" a ado A. _ft
FAX CELL7yyg/ MAILG I e / • . r . 4 1
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at raual-1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
RC<f to Ottz-2# 6.1:00JYes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It
PLAN REVIEW NOTES
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