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11 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,-,7- I�cz� CITY �r�l� (/YI()a3�\�1 OY1 S--t–� I MA I 1 APERMIT# c IR -147
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JOBSITEADDRESS a35 On IDOWNER'S NAME man J ) I
GOWNER ADDRESS I TEL (FAX I
TYPPERINT
CLEARLY
OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL EI RESIDENTIALE
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ N0�
APPLIANCES 1 FLOORS-. BSM 1 J 2 3 j 4 5 6 7 6 J 9 J 10 J 11 12 13 14
BOILER -
BOOSTER I I
CONVERSION BURNER w i -11I
li: r, i‘
COOK STOVE
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DIRECT VENT HEATER ,. " r ;r
DRYER r —r ii -1 z
FIREPLACE
FRYOLATOR
FURNACE I r
GENERATOR
GRILLE —I
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN f I 1
POOL HEATER
ROOMISPACEHEATER
ROOF TOP UNIT , 1 _ 1.111a rARM
TEST r I
UNIT HEATER
UNVENTED ROOM HEATER SAM MIN IIIIIIIIIIIIII an= MIR ME
WAT . . a SIM INS,—NMI MS WIIIIIMII Minn NMi
ill T SITZ . Sim. Ti■li�-SNINFI r it .�II..r.i.
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Iii/''..�1I�I� 1 f�ISIS'�I�M Ins am
it it Tr Tr -r- r r 7 T
INSURANCE COVERAGE ,qc
I ' gYrreil ji;Sr:i r nittl�rlrequirements of MGL.Cit,1df4Tce policy or Its substantial equivalent which meets the FPiliS)]NO ❑
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I '- to
' I ' ' 8,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -A
LIABILITY INSURANCE POLICY i►TI OTHER TYPE INDEMNITY p BOND '.3
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 0
SIGNATURE OF OWNER OR AGENT
I 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 applicatloin compliance wi , : nt provision of th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. $7
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PLUMBER-GASFITTER NAMECAMS .2.0_42–t 1 I LICENSE# phi SIGNATURE
MP) MGF❑ JJ�P,,,❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# I LLC❑#
COMPANY NAME:I `CuL(_ ks nDDRESS 7-7 1 1I4&IY _ S11'-p-oz-f- I
CITY (k,SeQA1 Le_ I STATE`' C41P Qait).S TEL `d Ha-$ -(o3(pS I
FAX 1 CELL EMAIL