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r:IA' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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AN'� ' I CITY rY .<n,. ,n7r I MA DATE a- PERMIT# 6m -i5-6-
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�`1 JOBSITE ADDRESS„3 (tJ 4 t'/i a— (OWNER'S NAME '%.gh 0(-j„16L�(1_ ,.06 I!
GOWNER ADDRESS L '1g.fki , ,, r!!'sdJ. i , , TEL97,6„pi n ? IFAXL_ I
TYPE ORt ��
PRINT OCCUPANCY TYPE COMMERCIAL CI EDUCATIONAL❑ RESIDENTIALL;I
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:LI PLANS SUBMITTED: YES❑ N :174.,3
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOOSTER A __II�I�I� � �jr�jr�
BOILER ], 1 I
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CONVERSION BURNER Iarri' IIIIII
COOK STOVE S 5Iil 1111 S I LS 111111.1I s I
DIRECT VENT HEATER " I,jp ___.
DRYER 11011 =ININIIIIIIIMISSIONNIIIINSMEMIONIEMINEINIKISIIIIIIIIII
FIREPLACEJ s wns I l s> inwtN111l_
FRYOLATOR Wb. �S�3fl� SfSS SS*W� til '
FURNACE r� tnMINEI_ I
GENERATOR ,�,� 11j;(_j ( 011111111 _
GRILLE EC co Ifl(IMIIIr SltSiS SS_INFRARED HEATER _
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LABORATORYMAKEUP ARUNOCKS �a IT l'am I ( S S
OVEN r...).11111( ����� � ���
POOL HEATER si I II I
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ROOM/SPACE HEATER I
ROOF TOP UNIT 11.11111111ISIMMU_ _u:n&ION
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UNIT HEATER INIIIIIMIIIIIINEIIINIEIIIIIIIIIIIIEIIIIIIONIIIIMIIIUIIIIIOIMIOIIINIMIIUINM
UNVENTED ROOM HEATER _f_iUS S EMMES _uIlIillaI1
WATER HEATERs V 5_u
OTHER 555 SSSLNS _
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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 Q NO"
I IF You CHECKED YES,PLEASE INDICATE THE TYPE OFCOVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND [I
OWNER'SINSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Maasacho • - General Laws,an• my signature on this permit application waives this requirement
ri_JIdo Aird,rh GNATUR A N R OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT D
I hereby atiy that all of the det rand information I have submitted or entered regarding this application are true and accurate to the best of my knowedge.
and that allplumbing work and Installations performed under the permit Issued for this application will be In compliance with all Pertinent provision of the
Mass achuutts State Plumbing Code and Chapter 142 of the General Laws.
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PLUM E;ERGASFITTER NAME LICENSE# SIGNATURE
l'AFP. IGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COM PAN NAME: &2 LIS,r,•r - I ADDRESS d '
CITY rZmo 2L/a+� ._I STATE/44dZIP Q/SL JTEL Li4&8 .l y.Q,.tS. ,...,:i
FAX I CELL EMAIL � ' '
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