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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ItDATE 51R 'q PER T#/tr0T/966"✓7
JOBSITE ADDRESS cOd Ce /tlu OWNER'S NAME
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: El RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NON
APPLIANCES 1 FLOORS—. BSM 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 COCKS
MAKEUP AIR UNIT f ,
OVEN
POOL HEATER
ROOM/SPACE HEATER °i,,Y ;•-0,.
•
ROOF TOP UNIT •
TEST
UNIT HEATER i
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES X NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY A OTHER TYPE INDEMNITY ❑ BOND ❑
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 El AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true a to the t of my owledge
and that all plumbing work and installations performed under the permit issued for this application will be in c 'th II erti provisio of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#/59aO SIGNATURE
MP MGF ❑ JP El JGF❑ LPG'El CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME it), Vprno6 O11iJP I Inc. ADDRESS d� ��//Q �, �
CITY O. NCAO,471 nn 42 C'_STATE l/1� ZIP �1 TEL �" J 0 v0
FAX CELL EMAIL
/611S1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# 7 h v (52//
PLAN REVIEW NOTES K
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