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' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'"kl_ CITY RIO rtviol MA DATE$fLflRnPERMIT# 6A/— /04/41
JOBSITE ADDRESS X Sf avyn ' t '(SiA le-f- OWNER'S NAME [At MLA/WI t7_
GOWNER ADDRESS TNQf7WO( 714(.0JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAIc0--
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES T FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER a NM 111.101111:111•111=3.1111.S100■I•S Sal an i5
BOOSTER MOO Mi OlaSs as
CONVERSION BURNER MINIUM O5lull.;siasssi[..era
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DIRECT VENT HEATER NM a ,AMISNAME O'mil SlaMIS Ma
DRYER EMOM WWI,MIN Mnig: i��s a
FIREPLACE a I•f,I.0111nMaaaaIraa, l
FRYOLATOR M.MornassasS ow Vis.
FURNACE .1.10111.01111OOTOOO1.11.11OO InIntint a.
GENERATOR MI1.111t,MOSINIOC1=11C,_COMMIS
GRILLE all ONION. AIMIla,IO ME 111111,111.1 5aIM,i
INFRARED HEATER MONS OAP.$•.0111111.11111.,la ISIEOSSE a-'fI
LABORATORY COCKS IIIIIISONcinaCiml,C a a ma 5555
MAKEUP AIR UNIT lag 01115.111MIONNOMM MIS NM___ sMi,[a-S1S.
OVEN SIMMI;�**r I Via-aSS.STi
POOL HEATER poi swam rpm pm ,s JOISPIni Wein at_,
ROOM!SPACE HEATER 5[MO Mr,Illik__ _sllis_s_s
ROOF TOP UNIT S [ar si O s111O 555
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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 ❑NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are s a and accurate to e best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be Inc' Iia ce with •- ' ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �,
PLUMBER-GASFITTER NAME j 4p pi T C,s-m , ii
mA LICENSE#T / /NATURE
MPiaMGF❑ JP JGF❑ LPdI❑ CORPORATION U]PARTN •SHIP❑# LLC 0#
COMPANY NAME: (Pm—PIumb,rr `, ADDRESS / Gtl.cl 1ln5+-oil ...g 0-7A
CITY 1 7/lOp/(J STATE /1T ZIP 02.t&5 TEL EI-01- ,
�- 1939- '7')
04/ 1
FAX CELL EMAIL'1m0)61 L1M 0 0.7e m Ovn\'o vl4`r CO M
5 5I9 &). 2k
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT t#
PLAN REVIEW NOTES
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