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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING
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-1'i fl _CITY/TOWN: r �^ STATE:MA APPLICATION DATE: 5 I t 8/tt
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JOB ADDRESS: K
GOCCUPANCY TYPE: COMMERCIAL❑ RESIDENTIAL PLANS SUBMITTED: YES NO0
NEW': ALTERATION❑ REPLACEMENT❑ REMOVALJDEMOLITION❑
r NATURAL&LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT-APPLIANCES-SYSTEMS 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS
AIR ROTATION UNIT FURNACE: ALL TYPES r -1 TEMP HEATING EQUIPMENT r
BOILER:ALL TYPES ,-1 GAS PIPING r-- THERMAL OXIDIZER
BOOSTER --7 GENERATOR(STATIONARY ENGINE) 1— TURBINE 1
BROILER —1 ILLUMINATING APPLIANCE j— UNIT HEATER
BURNER: ALL TYPES _1 INCINERATOR j----" WATER HEATER: ALL TYPES x
CO-GENERATION UNIT —1 INDUSTRIAL AIR HANDLER 1 EQUIPMENT OVER 12,500MBH
COFFEE ROASTER _1 INFRARED HEATER I FOTHER NOT LISTED1
COOK APPLIANCE HOUSEHOLD ( KILN 1 GLORY HOLE I CRUCIBLE
COOK APPLIANCE COMMERCIAL —1 LABORATORY COCKS I
DECORATIVE APPLIANCE 1 MAKEUP AIR UNIT r-1
DIRECT VENT APPLIANCE ( MECHANICAL EXHAUST EQUIPMENT I
DRYER: ALL TYPES _1 OVEN: ALL TYPES 1--1
FIREPLACE:VENTED!UN VENTED POOL HEATER I I
FRYOLATOR ROOF TOP UNIT I _
FUEL CELL 1 ROOM HEATER-VENTEDNENTLESS I
�����, PLUMBING/GAS FITTING FIRM INFORMATION CHECK ONE ONLY
NAME:L'"' •D 1(U4n611`s I ADDRESS:II° SouktlxStPtlwitt'2- a ['Corporation Business I
CITY: 2&P't• �L 'STATE: MA ZIP: . •::: „..472,7,„„......j 9Paflnershq Business:LLC Business i l
TEL:;11`t'Lt2-229k1 FAX: — 1 EMAIL: ❑DBAIUnincorporated
NAME OF LICENSED PLUMBER!GAS FITTER: \Cwu� <OCWFLL.L, t
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YESI2 NO❑
If you have checked,please indicate the type of coverage by checking the appropriate box below.
A liability insurance poll Other type of indemnity❑ Bond ❑
OWNER'S INSURANCE WANE •I am aware that the licensee does not hav4 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 Owner's Agent
OWNER'S NAME: `3 t) Swww%uw ' -7 TEL: I FAX 1
I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to
the best of my knowledge.I certify that all plumbing work and installations performed under the permit issued,will be in compliance with
all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws.
(OFFICE USE ONLY) Type of License: - 7
Perini#G 1 ®Plumber ElGasfitter I
Inspector^--- 11430{, am; ❑Master 0Joum �ar� E " ' UA
Fee: . fLicensedPlumber!GasFitter
1 2 — H ❑Undiluted LP Installer -License- Y 3`)Sa?
❑Limited LPInstaller AL 1 3 2011
pull
By:
ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT•
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PLAN REVIEW NOTES