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MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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uCITY Town of Y 1�. MA DATE O PERMIT#/g' 41"0d2 373
' JOBsrTE ADDRESS& 1 ?a- f'j _a OWNER'S NAME M„� ,,9L, _ I
• G OWNER ADDRESS [ - _ I 791 331 2,35-349C, 1FAX 1
TYPE
PBINblt OCCUPANCY TYPE COMMEREIAL'tLi EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:Li RENOVATION:LI REPLACEMENT: PLANS SUBMITTED: YESf NO0
APPLIANCES 1 FLOORS-* 1 2 3 4 5 6 7 ° 8 9 11:1 11 12 13 14
LIJ ar, ION BURNER
>i VE
\ - HEATER _
LIJ ` ^�DRYEER I !_ I
i (-)ib OFV R
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• INFRARED HEATER >� =Am ILIIIIII[''III>Een NMI NM Millf NW IIIIIM';11111111:MIM[
LABORATORY COCKS --_w[111111111=>l y> WL :k.1.4 41U.. • ,.•:L;S JIM
MAKEUP AIR UNIT 11111111M111111=:Miff.K_ L 1Ca:: -' L.Ji u r... 71.1111
OVEN M i,44i1 L. l 44 L. '-,—l. .t -
POOL HEATER , _ , ,'i- 1 .; -.
ROOM 1 SPACE HEATER _ •
ROOF TOP UNIT r
TEST
UNIT HEATER C
UNVEND ROOM HEATERE" — -
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OTHER . r _ .- -- - —
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INSURANCE COVERAGE
I have a arrant&ability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES [1�NO 0
1 IF YOU CHI YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABDITY INSURANCE POLICY 12 OTHER TYPE INDEMNITY J • 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 Q AGENT 0
SIGNATURE OF OWNER OR AGENT -
I hereby certify that al cf the details and kdonnaeoe I have submIlted or entered regarding this applicalon are true and accurate to ; -best of my knowledge
and that all plumbing wort and irons performed underihe permit issued tor1his apeman will be In corm s - Ixovteion of the
Massachusetts Slade P Iwnl*rg Code and Chapter 142 of the General hers. /f�
PLUMBER-GASFrf TER NAME I kgv;, m C-B&:,p. 1 LICENSE# 1 1 6 9 01 - - �- - SIGNATURE
MP a MGF 0 JP Q JGF D LPG!El CORPORATION ditte3 8(,1G 1 PARTNERSHIP i fC D#1
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COMPANY NAMEl1?rwn'rnc'Brt J& Rom 441 a Sltc f ADDRESS' I I rinc.i.rocPi' PO4A
an' a).y�Ay+n�-�'� • I STATE ZTPJ aak.73 f T L (sa 0 ii 4 5a I •
FA4 ymo-67ZiCELLI og 364-370/41 ILK km�p I id on L c...r)m cdsf , ne—i-
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