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-,� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`:t t`=;0 CITY S �l c"M6�'1YZ MP, DATE 7-2 5.— II PERMIT#IN/7 0 �7j
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JOBSITE ADDRESS 3 0 WC'
r"e `-'1 v OWNER'S NAME --\0 k 11 U
GOWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL
PST ❑ EDUCATIONAL ❑ RESIDENTIAL lig
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT.10 PLANS SUBMITTED: YES❑ NO❑ I
•
APPLIANCES FLOORS-4SS1v1 1 2 3 1 5 6 7 8 9 10 11 12 1; 1 h. !
BOILER ---I
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE •
INFRARED HEATER
LABORATORY COCKS / ,, i
MAKEUP AIR UNIT `n r
r 7 i )0
OVEN i
POOL HEATER
ROOM/SPACE HEATER
I
ROOF TOP UNIT
TEST - ---
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
OTHER _ I
_
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
LIABILITY INSURANCE POLIC' 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement. ;
I
'` CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT J
'3:!:: 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
i
Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
PLUMBER-GASFITTER NAME � . 14�tir-4-1.1arN LICENSE# /54322 SIGNATURE
MP( MGF❑ JP ❑ JGF E LPG! ❑ CORPORATION❑4PARTNERSHIP❑# [lc❑## I
COMPANY NAME O n ra e-1- ADDRESS P3 [2=r3X
CITY Cam'•f-e-c`J'G kArc._ STATE MA- ZIP c)2C9T2 TEL .174''1-?E,-6 2 bCe
FAX CELL EMAIL r 10.n rio g1ur,'*lo )'1.1e6M Ai; ,4.1,A
/`'//
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
thO' v FEE: $ PERMIT fE
PLAN REVIEW NOTES
7 0.1&4?