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MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM GAS FITTING WORK
CITY
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� I q MA DATE PERMIT# 1?"66-2 4- l 4 4
(� JOBSITE ADDRESS OWNER'S NAME 2/
E '
to OWNER ADDRESS ! /7 TEL 7/.)2—Y3 FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL 14_24--
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES❑ NO 10
APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12
BOILER ! t4
BOOSTER
CONVERSION BURNER
COOK STOVE -
DIRECT VENT HEATER -
DRYER —
FIREPLACE
FRYCiLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM I SPACE HEATER --
ROOF TOP UNIT
TEST .
UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER
OTHER r!0 /
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 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY X, OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I ant 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❑ 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 accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code an Chapter 142 of the General ws. i y i/
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PLUMBER-GASFITTERNAMEf I q -✓rt(-)3r' �" LICENSE(#� SIGNATURE
MP❑ MGF D pp JP-IT-JGF El (LPGI❑(� CORPORATION❑# p rO 1 PARTNERSHIP❑it LLC 0#
COMPAN`f{NAME y r-r CQ2 N MVt ADDRESS 11 7 1--ram/L I17l Acre >
CITY % STATE ZIP C/ 7.V jJ/ TEL i1 7/4 l/Z`
FAX CELL EMAIL'5 1-P/ /lit(-13 ri 200, C L• (s
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT#
PLAN REVIEW NOTES