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___ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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MA DATE ill PERMIT# b Lv(,- Z y7
JOBSITE ADDRESS 1-7 ' "� ------- LLL
OWNER'S NAMEr(-• f LA-.S 1
G OWNER ADDRESS
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TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL _ . RESIDENTIAL Z CLEARLY NEW: RENOVATION:J REPLACEMENT:
PLANS SUBMITTED: YES 0. NO
APPLIANCES 7 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER __Li.. _____I I __1__J—J__
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BOOSTER -
CONVERSION BURNER j. ,_ 1
COOK STOVE - i_ . .I--1_J:. - (:,_ 1 I
DIRECT VENT HEATER -_ —1 —J —J—�—J—J—1 I I I
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DRYER- -. i. .. —_ J-__f •
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FIREPLACE -- - - - -. . _.. __ -- I.. ..... i -- I
FRYOLATOR -- -- _ ..... _..--_.. _. - ____1_I____� I ( !
FURNACE _-_ ._ ....
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I GENERATOR _ .. .. -_- - I - I
GRILLE I---I I--I---I---} I I I I
INFRARED HEATER -J ____I_____I I-.J I'—_! - -I. _ . .
LABORATORY COCKS I ' - ��I_j - _ iit _ —J—1 I
MAKEUP AIR UNIT
OVEN NNW ,... - ,_1_I__1 Et__-_I___ I M "�� IMI i
I _. .I___1__-_1 .. I_ i
POOL HEATER _J_1 I_J I_ 1 '_J___a ALINKIIIIIII
-�.I EROOM/SPACE HEATER I I__ I f I_ I I I . _I
ROOF TOP UNIT _ I 1 I 1 E i I I
TEST i_� F j 1 I i i 1, _ 1111tM , i� .
UNIT HEATERI lilt f -`-' iPl:1] - '- -- I
1 I I - j�...J_ j
UNVENTED ROOM HEATER _J_ : i 1 -I I I
WATER HEATER _r-J . I I I ._ I I J� _.J_�
OTHER ,____1 l. I
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t INSURANCE COVERAGE _1 f I I! E
14
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES li NO =I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Y OTHER TYPE INDEMNITY 7,LE BOND Li
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 II AGENT __I
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 my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i compliance wj h alj,Pertine t provision of the g
Massachusetts State Plumbing Code and apter 142 of the Genera Laws. ��
PLUMBER-GASFITTER NAME �r6.1_ Q�C` /�16Z('�. -- LICENSE# 9 b } SIGNATURE
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MP _I MGF=-_I JP gj JGF LPGI L. CORPORATION #7. ------- -.f i PARTNERSHIP.� .�-w# M LLC:_(# '-
COMPANY NAME:' l -f I _
L� �.1�-----i.ADDRESS `j7/-( ALt,
CITY iciAm 1, STATE 1 ZIP: (a D / �TEL 77�Yr� FTz
ELL: EMAIL /c 1i-ef 0 M 4_A ri 4 -,(t,A4-1. L- t (' 0 Av1 I