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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY (Yamauth
MA DATE 0/2-21
JOBSRE ADDRESS I ) 2 d—(_2 dI )a'i) 5 'j- , OWNER'S NAME I •,/ 4.n
G OWNER ADDRESS: I y a r d11 ger net)
I
TYPE OR TEL: FAX
PRINT OCCUPANCY TYPE COMMERCIAL d EDUCATIONAL 0 RESIDENTWL)2!
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑
PLANS SUBMITTED: YES❑ WIZ(
LER
RES 1 FLOOR- Bsmt 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOOSTER
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SO`O�N BURNER
COOK ST
DIRECT VENT HEATER
DRYER _FIREPLACE
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F OLA70R
FURNACE
GENERATOR
GRILLE
LABORATORY COCKS
V
O
VEN PAIR UNIT
POOLHEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER N� * era �r_
UNVENTED ROOM HEATER
WATER HEATER —_�_�__���-__-■_
MIIIIIIMI
• SIllt --- ttiINNI
I have a current liability Insurance policy COVERAGE
policy or Its substantial equivalent Mitch meets the requirements of MGL Cit.142 YES Z1 NO 0
K you have checked MS,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUCY2Z1 OTHER TYPE INDEMNITY 0 BOND
OWNR'S INSURANCEGRWAIVER:
and that that the licenseecoverage� 0
my signature on this permit Insurancemthby Chapter 142 of the
waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that at of the details and information I have submitted(or entered)regarding this
Knowledge and that all plumbing work and Installations performed under the pent Issued for this application are true and mplla, to the best of ne
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. pplkalbn Mil be h compllan with seined
provision
PLUMBER/GASFITTER NAMELi G,Soh o CT.ca.1'thn I LICENSEt da33y SI TURF
COMPANY NAME Innilapaainaa
ADDRESS 11 or fs G,On CI-0_54y' d
CITY: I Ce'r i-r r IIP_ ISTATE: zR I o ?me; S
TEL: F O'`� --?- . FAX I
I EMAIL I I
MASTER 0 JOURNEYMAN,LP INSTALLER 0 CORPORATION 0 yI _PARTNERSHIP 0 pU LLC❑pr—_
x�rE[iSE ONLY SIAL INSPEC^ON NOTES
BELOW FOR OF
ROUCH CAS iNSPE['170N NOTES �?
_ + .e �� kr— .ti.irwnnt�_ r-E.\ p5 THE PERMIT_ e1 0
tit
FEE: $ FERWTt_�
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