BLDG-19-005519 V W,nSIuu 1A,'l4 7
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
6'' CITY Y9kmdWA, U
4^; ';:-_' / GU�$1 1�1P, DATE .372fi0l PERMIT# /9 Q6.JOBSITE ADDRESS / N 13u SP,( f? . OWNERS NAME
OWNER ADDRESS TEL FAX
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TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL f
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOV' 1
APPLIANCES 1 FLOORS--I 6SM 1 2 3 1 5 6 7
8 9 10 11 2 1� 13 14
BOILER __1
BOOSTER
CONVERSION BURNER, I
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR I ���
FURNACE I /
GENERATOR 1
GRILLE
-
INFRARED HEATER � w ._. -.a - _ ..t._...... I j
LABORATORY COCKS F R E ( r '
MAKEUP AIR UNIT j
R
OVEN / �
POOL HEATER -1 M*r� ? y 2ti lt''
ROOM/SPACE HEATER €
ROOF TOP UNIT Bu'L'_(M 41W 1. '+`
TEST m -
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I j
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 160 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
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j
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
` Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑ I
SIGNATURE OF OWNER OR AGENT J
-I, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in cormpyIiance with all pertinent prow€ ion of the
Massachusetts State Plumbing Code and Cha ter'142 of the General Laws.;Lt.},
� o m CDulf>-E--A"iv
PLUMBERS LoZ .NAM LICENSE# /17-$ya9 SIGNA E
MP MGF❑ JPn[ JGF t❑',,LPGI ❑ CORPORATION # 4D,S'7L PARTNERSHIP❑# LLC❑# j
COMPANY NAME A- f'p�CJ_a-e-R-Fry )4'CdOL/A1 -' ADDRESS c30 M ai s c7 �U 6
CITY y/4 A-M Ou` v, STATE /4 f ZIP d a`-G 7.,;-- TEL Son'- 7 3 9- avo
FAX CELL��AF- 7 t9-803 EMAIL'70i m/c /.37 Q 6/ /L, ciAA..,
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yee No N/& S/i)/z
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 1c LL /lai.cc
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FEE: $ PERMIT#
PLAN REVIEW NOTES