BLDG-23-8808 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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e CITY "ft. c rr1a.
y MA DATE 571(S ,--q PERMIT itbC Z3' �{D
JOBSITE ADDRESS 75 5A4-; ,-, �Fu f - OWNER'S NAME 54w.cJ:-`, til
GOWNER ADDRESS TEL
TYPE OR FAX_____________
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ei---/
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BEM 1 2 3 4 5
BOILER F7 8 9 to 11 12 13 14
BOOSTER
CONVERSION BURNER
COOKSTOVE
DIRECTIII
VENTHEATERi
DRYER
FIREPLACE i
FRYOLATOR
FURNACE
GENERATOR
GRILLE /
INFRARED HEATER
LABORATORY COCKS
, MAKEUP AIR UNIT
OVEN
I
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER - - -- -.-
UNVENTED ROOM HEATER
WATER HEATER
F V U
OTHER ._..__-------
I
BU LDINGDEr•RrMi NT
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES'6-p0-0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 8' 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
Mae r usett eneral Laws,and that my signature on this permit application waives this requireanent.
SIGNATURE OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑
`.i- I hereby certify that all of the details and information I have submitted or entered regarding this application are t e 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 inrn lianc 'th all Pertinent provision of the
Li I
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C I/
PLUMBER-GASFITTER NAME g 1/ '1 3°I U l LICENSE B GNATURE--
MP❑ MGF❑ JP D JGF❑ LPGI❑ CORPORATION❑tt PARTNERSHIP❑# LLC❑#
COMPANY NAME fog,-e_ Y+ G. ADDRESS 5' 5---0-,J..cJI_..
CITY ^n,S��. STATE✓t'I : U' , ZIP 9-a(3 1 TEL
FAX CELL ! / S.34,(o-ao / EMAIL
Mcr1 ocr, e2 X 6 f 64i4 e_•Ce Al
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