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-N'' MASSACHUSETTS IJNIF RM APPLICATION FOR A PERMIT T PERFORM GAS FITTING WORK
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` ,_ CITY MA DATE PERT T* 6__
JOBSITE ADDRESS OWNER'S NAME 4
OWNER ADDRESS TEL it_F )'
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: V REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ l
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APPLIANCES 1 FLOORS—I BEM 1 2 3 4 5 6 7 5 9 10 11 12 1-
BOILER —'�
BOOSTER —�
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CONVERSION BURNER ,
COOK STOVE
DIRECT VENT HEATER
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DRYER
FIREPLACE I
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER --7
LABORATORY COCKS
MAKEUP AIR UNIT I
OVEN ��
POOL HEATER ,�rye
ROOM!SPAC;E HEATER 77 I
ROOF TOP UNITl,� =
TEST
UNIT HEATER '
UNVENTED ROOM HEATER
WATER HEATER
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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 COVERA .BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 i
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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71 CHECK ONE ONLY: OW R ❑ 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 and accura` o the best of my knowledge
`s- and that all plumbing work and installations performed under the permit issued for this application will be in complian .with eft n vision of the
` Massachusetts State Plumbing Code and Chapter.42 of the General Laws.
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PLUMBER-GASFITTER NAME//C "227W,9 LICENSE#42�`' SI NATUR
MP ❑ MGF El JP GF❑ LPG' ❑ i' 'ORATION
/� ❑# PARTNERSHIP❑�� LLC❑#>
COMPANY NAME/' / . ADDRESS , ��1,
CITY 1/ z , / 6/ - STATE ZIP T
FAX CELL EMAIL
&OUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It (y
PLAN REVIEW NOTES --(/6"/ )00
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