BLDG-15-002461 l -.4'. MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
r. �_ CITY: \li4g{'14000L& MA. DATE: /0l3/ y PERMIT#ineraaafl&I
JOBSITE ADDRESS. aS L Ao , OWNERS NAME PN f
G OWNER ADDRESS: TEL: FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDU TIONAL 0 RESIDENTIAL®/
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO V
APPLIANCES? FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER •
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST -
UNIT HEATER
i— UNVENTED ROOM HEATER
i WATERHEATER '" I j
•I ft r 1 I7 r- rt.
INSURANCE COVERAGE —
i_ I have a cu ility'uisurance policy or its substantial equivalent which meets the requirements of MGL . 42 NO ❑
If you have checked 'ES,please indicate the type of coverage y checking the appropriate box below. OL 3 1 2014
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 :BOND_❑_D ld157rT
fr OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Cit roO
Massachusetts General Laws,and that my signature on this permit application waives this requirement
S re
CHECK ONE ONLY: OWNER 0 AGENT 0 ?V.
SIGNATURE OF OWNER OR AGENT
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 incompliancewith all Pertinent
,40
provision of the Massachusetts State '
/`�.Plumbing Code and Chapter 142 of the General Laws. s (�/�'r.Lvf
PLUMBER/GASFIITER NAME:�6/7/ Poo tisLICENSE#d/op/ SIGNATURE
COMPANY/NAME ^Jlrl� S P/l/f1J/.�9 ADDRESS: NO sOc) 70,2
CITY•/. illi STATE I'44- ZIP:n, y 63 FAX:_ 30ot WC/-
TEL:5 0 7 3 VS1r CELL: EMAIL' /1-?)/4:11.5 /0 e/fr oZ 'COT./
MASTERJOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LLC p
v '_ f
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT/
PLAN REVIEW NOTES