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1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`•-1c� CITY �iU;�F,.' f1 4 MA DATEIIII�.garsPERMIT# —��d �G
JOBSITE ADDRESS Uglit1J f in OWNERS NAME
GOWNER ADDRESS TE FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL Q RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES E] NO❑
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILERIIIIIIM
BOOSTER MIUMISSMISINNIMSSMEilliketilita
CONVERSION BURNER
COOK STOVE �111111IIMII1111111I11111_310a11111j�j111111111I10S
DIRECT VENT HEATERINIMINNI-_ .WASMIONI _ INNM
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DRYER s n_fl I I__s55 55*
FIREPLACE ... sI�I ---- �� _. .
FRYOLATORWilailialiarinal00110011101010111111101111011110111000101/
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FURNACE I K
GENERATOR
GRILLE SINEWS SWiliataaiMISISIMIS
INFRARED HEATER I VIII I I0EIEI MISS irk
LABORATORY COCKS 555555555555555
MAKEUP AIR UNIT 5555 5551 -I_SI� IKIl1
OVEN I IIIb SI5IONIINIIISS lMIL
POOL HEATER ILII s _ __ _ IIM' n
ROOM/SPACE HEATER I> _ I I '
ROOF TOP UNIT _ I
TEST
UNIT HEATER 1.1111111111101111101111111111011.101111111011111100111111111011111011.01nala
UNVENTED ROOM HEATER II
WATER HEATERS ' ' _,
OTHER — ------S ,—S 'I '
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ElNO Q
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY Q BOND ❑
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 [j AGENT
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 application will be In compile. - •ith all Pe•••- t provi '.. • he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - - �
PLUMBER-GASFITTER NAME Cc.“- 1 5 . R e d e. 11 LICENSE# 8 6 S ATURE
MP MGF Q JP Q JGF❑ LPGI Q CORPORATION Of PARTNERSHIP0# LLC❑#
COMPANY NAME: ( art fr. Riedel ( t Son ADDRESS 77 Mc. in Street
CITY ostcrvtlle STATE MA ZIP ea655 TEL 50S- 4a$ - (p3G5
FAX CELL EMAIL • /
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