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i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING ,
C _':"_.L CITYITOWN: -�' �tN� z 'L
C. _:L'� STATE:M. APPLICATION DATE: T�� J
JOB ADDRESS:i iO e ce—i'rift' vYz (.U' `i 4c r✓✓f ~�
GOCCUPANCY TYPE: COMMERCIAL0 RESIDENTIAL PLANS SUBMITTED: YES 0 NO[gK
NEW ALTERATIONS REPLACEMENT REMOVALNEMOUTIONO
t NATURAL& LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT-APPLIANCES-SYSTEMS 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS
AIR ROTATION UNIT i FURNACE: ALL TYPES r-1 TEMP HEATING EQUIPMENT r1
BOILER:ALL TYPES i GAS PIPING THERMAL OXIDIZER
BOOSTER _"-1 GENERATOR(STATIONARY ENGINE) f TURBINE p
BROILER -----1 ILLUMINATING APPLIANCE r— UNIT HEATER M
BURNER: ALL TYPES ---1 INCINERATOR r— WATER HEATER: ALL TYPES r--)
CO-GENERATION UNIT —, INDUSTRIAL AIR HANDLER r EQUIPMENT OVER 12,500MBH r—t
COFFEE ROASTER 1 INFRARED HEATER (' VOTHER NOT LISTED1
COOK APPLIANCE HOUSEHOLD —1 KILN I GLORY HOLE I CRUCIBLE r- r-1
COOK APPLIANCE COMMERCIAL --( LABORATORY COCKS L
DECORATIVE APPLIANCE —1 MAKEUP AIR UNIT I U
DIRECT VENT APPLIANCE 7-1 MECHANICAL EXHAUST EQUIPMENT
DRYER: ALL TYPES ( ( OVEN: ALL TYPES
FIREPLACE:VENTED!UN VENTED I POOL HEATER
FRYOLATOR I ROOF TOP UNIT i
FUEL CELL ______I ROOM HEATER-VENTEDNENTLESS I ,
PLUMBING�/GAS FITTING FIRM INFORMATION CHECK ONE ONLY
NAME:: CM. CA P444 1-- ADDRESS: P D. a0 X 'l 2 j] tLJJr(o poraUon Business/
CITY:L FS. DeA/NI 1' (— —1 STATE:[IIP:F-07---1.A n -_� R ' '
Business/TEL: �,} '3RA'LZZ� FAX:! 1 EMAIL: LLC Businesst
�j / I -I ❑DBAIUnincorporated
NAME OF LICENSED PLUMBER 1 GAS FITTER: B/2.1,44/ N I bh
INSURANCE COVERAGI
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0,1(0❑
If you have checked In please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of Indemnity 0 Bond 0
OWNER'S INSURANCE WANER I am aware that the licensee does not have the Insurance coverage required by Chapter 142 o1 the Massachusetts General
Law;and that my signature on this permit application waive;this requirement
CHECK ONE ONLY
OWNER❑ AGENT El
Signature of Owner or Owner's Agent
OWNER'S NAME:1 — I TEL• `' EI------ II
I hereby certify that all of the details and Information I have submitted(or entered)regarding this permit applicati 19,4u da to
the best of my knowledge.I certify that all plumbing work and installationsperformed under the permit Issued,will in wi
9tr
all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the Genet,I L< Iti
(OFFICE USE ONLY) on(-Mil_ ft 0 0
Type of License: BY:
Peal#1— -7 1 ['1PI ber Ettaslitter c t 1 -
Inspector ' Master ❑Journeyman Signature off L—ker�aed—Plumber;Gas Fitter
, ['Undiluted LP Installer license Number. 1i 7S 77
Fee:��, .V�� J
❑Limited LP Installer
ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMITS
PLAN REVIEW NOTES
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