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" - oit SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CIT +�I -�'vn ° {/Ci MA DATE /0_,'_.2e3•� IT*
OCT 06 2 2,75B TE DDRESS 9 710 MI--�� IMERM —'
I ■�/^,1� tt��, OWNERcS�7NAME �-�'t-7�/�CY/�
eu,„„, uEEA_(NENE: 'DRESS f� ��Q �l' TEL I,�vc�fAX
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PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL
CLEARLY ❑ RESIDENTIAL 0
NEW:❑ RENOVATIOIREPLACErv1ENT:❑
PLAfJ:,SUBMITTED: YES 0 NO❑
APPLIANCES-1 FLOORS BSM 1 2 3 4 5 6
BOILER _ 8 9 ill 1'I 12 13 14
BOOSTER _
CONVERSION BURNER
COOK STOVE il _
DIRECT VENT HEATER
DRYER _
FIREPLACE - _
FRYOLATOR 10
FURNACE
GENERATOR
GRILLE . -
INFRARED HEATER
LABORATORY COCKS _ ______1
MAKEUP AIR UNIT
OVEN
POOL HEATER _
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER _
UNVENTED ROOM HEATER -
WATER HEATER
OTHER
I
INSUANCE
I have a current liability insurance policy or its substantial equiva ent which meetsE the requirements of MGL Ch.142 YES ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ] OTHER TYPE INDEMNITY ❑ BOND 0
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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT❑
)) I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to thetest o
`,
and that all plumbing work and installations performed under the permit Issued for this application will be in co Ila kn edge
LEJ
Massachusetts State Plumbing Code and Chapter 142 of the General haws, rtl t prov si n thhee
PLUMBER-GASFITTER NAME 6),re l ✓" 11/ LICENSE b I SIGNATURE
MP 0 MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION❑4 PARTNERSHIP 0# ) �LLC❑#
COMPANY NAAME///}}},,,��I ADDRESS /9 cJ c— T�Q IN�
CITY �1 I �"l_ //''��SS(TTyA��T ZIP n J v TEL
FAX CELLS--ail oo EMAILfY)('(c meo,a V r L \
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OUGIi GAS Ii PdC3`I'ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
*(SPEt� IOrI
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
• FEE: u PERMIT#
PLAN REVIEW NOTES