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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-B /a��, CITY LJe,�`{ y�r�s� __—^.--� MA DATE _y I30 //� � PERMIT# �l I,�/-p'1r-�d u�'97
JOBSITE ADDRESS as ( er-f--n-1Qod-,4- Joarf.2.._ IOWNER'S NAME �S-% \c3 Iec L ____
GOWNER ADDRESS .1TEL OBI)a?S--4/S36 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL —J EDUCATIONAL J RESIDENTIAL SCD
PRINT
CLEARLY NEW: 1 RENOVATION: J REPLACEMENT: p PLANS SUBMITTED: YES __I NO__.J
APPLIANCES Z FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER J _.____.I _.___I J i _. ___.1 ___J I JJ ..__ ,
BOOSTER J J 1 — J --J J I I--_1 --J J J
CONVERSION BURNER ' ----_—_1' I I _J _ ._1 __._J I'_.____I _J J -_-__J __--J
COOK STOVE _I ___ I --_-J-___-J 1 I_ I_ { I I I'_._1-___l'_ 1
DIRECT VENT HEATER J _-- J --J I __I __I I'------1.__-__1_.__I. . J I ----J -- J _
DRYER --____1_ I 1 I J _1 1____ I I J' I 1 _-___-1 -
FIREPLACE __._J____.J _._—.J I — ' 1 1 I'___..J_____J I _____J __..__J .._
FRYOLATOR __..J J __._-_J_J —1` I ____ ___J I I I _ 1__.__J ____J
FURNACE ___J I _--__J JIII __._-J' I _J1 I _ I ___J _ _
GENERATOR __I________I J -..._J I 1___J I _ .J_.._.__J _ 1______l__.__.I .___.
GRILLE i ____J -_.J-.,1'_._J._.____l __._ __...__I -_.____I
INFRARED HEATER
LABORATORY COCKS ( I l _..___1 ____..J ____I 1 _-_..-__J _-_J __. 1 _ I _-.__l .__ _J _-_-_J
MAKEUP AIR UNIT J J_ .___I J 1 .___J -.._,.J I _._._J _J -___I ._ __J __J I
OVEN __I _ .____.! ____.I _-___J _____J __._J ____ _I .._.._J __.J, J J' I _J ___..I -
POOL HEATER I J J ____J____1_ I___.._ I _ _ . ._-_l-__J .-_I ____._I __-__ I _.J
ROOM/SPACE HEATER - --1 _---J - ---J ---1 1 I _--J I I ____J______
ROOF TOP UNIT ! _._J J .______I ___ I __ .-I __-.-_I ____-I __-_.1 -_.___1 __J -____.1 .__.__. J '
TEST J 1 . J --I -___I - J ---J J --I - I -J J '
UNIT HEATER I I _ 1 __J J; J J _-___1 I .I J J f�-�--�
UNVENTED ROOM HEATER __ i
J
WATER HEATER ._____ - -.__J __1 I-_ l ---J' _ . W. 1g' 1 ___J __ i I
OTHER I ____ .l ___.__.l I __-__I ___J __-- _1 ______ I ___.! ---- ..J r i I __-_I ___ I I
. I ___-_ _1 _-e__J _l ______J..-___J ___J'_ _J -------I .-___J
J _J l J I _ _J .._._._J _ J
1 ----_1 _.-__J ____J _ ! J - J J _ - I -.--J _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _J NO __J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY _-J OTHER TYPE INDEMNITY _1 BOND I__1
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 __J AGENT __J
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 accurate to the best of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp' e •th all Pertinent pr sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .
PLUMBER-GASFITTER NAME 3-40. is l s I LICENSE# I 3a IGNATURE
MP b MGF . JP s JGF LPG! __1 CORPORATION _J# PARTNER J# I LLC _J# J
COMPANY NAME: 5 -- _I ADDRESS 1 5`b w1.•1T;v., bc_;,te_. j
CITY 0c.4 4.7s I STATE tillk I ZIP 02_ 03 S 'TEL c , 2 g o 5.13 _____'
FAX CELL !EMAIL kC11.(Te(-h,:.-,c'.a,•t eLed .rST -T — .
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ r PERMIT#
PL4N REVIEW NOTES
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