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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
MASSACHUSETTS
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-_1 a� CITY ' CA _�-__-._r_. J MA DATE r\ I-7-1 PERMIT# al-a--/7 V" 2,
00 JOBSITE ADDRESSI1._ '(\C"< -c•1pc-h_..__ ....D OWNER'S NAME 1 NCe_.\\,,e___ 1
(5 .)• V OWNER ADDRESS ! �C..c-� ���h Pc�k_ . {Tali IFAX�� TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL L RESIDENTIAL
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CLEARLY NEW: : RENOVATION:0 REPLACEMENT:A_ PLANS SUBMITTED: YESEJ NO„J
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
• BOILER �- -I:, -_,_ i -' I_�� L. y''
BOOSTER I I I: __ _-` 1. _ 11,- —
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- CONVERSION BURNER aI ' -.-_ L-- -__ 1 .___I ' a I 1` 3
COOK STOVE --i `:i : _L :1
DIRECT VENT HEATER I- `1 =I -.1—`f 1I -` — .I aI .i ,
DRYER .__ L__ _I__— L____L— —— •I_ :=I_ ._; —._ I 1; l__ it _-
FIREPLACE - _ ' 'L_ .—. :ILJ - L-_____i;7-7 r= ____=1__ ___ _ a_:-_;
FRYOLATOR I _ 'I ___1.._ _I.-_...1__._ .'1 _ ._.L -'I_ _ i . 1.--._ - il_ -_
FURNACE I IL,__._
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GENERATOR w _____'..____'1_._r _..- '1: _ .__
1 ...._._ I. II 1,..-:__ i
GRILLE L__ �ai_,._ '�---�_=I,F , I _,_,._.�. = � ._...� ._
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INFRARED HEATER 1___.�______I:._ .,. ,._ _, :__... .__.�.; I =. ._. __�z ,_._ .:�.-___ � ._. �. �1I__.-.�
LABORATORY COCKS �.�-' 'I 1--_ _- -- _.�_ �t- - ' . - _____
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MAKEUP AIR UNIT I ,�'1 1_ : __I. I
OVEN . 1 __;I:.._=1.—_•—_I_—._ I. fl ,-_—i:1• 1 .._ I_ — i _ `1
POOL HEATER 1 j = El— ''
ROOM/SPACE HEATER I Ati_-__71I . _I.-_, I-_ I__ I __ ___171 ! .1_._-1
ROOF,TOP UNIT I : ;.I I. I. i l,-_1---
TEST 'I._ :1`.__ ___ - _L. __.._
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UNIT HEATER _ 1 v.-._ ___-
UNVENTED ROOM HEATER L 7,I___, -i. I._ !I______;;I_____ r--
WATER HEATER - I_ � _. _-- _E . I I
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OTHER ( I I 1 I I I I L
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES WNO U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY ! BOND Li
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__..1
•
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 complia ith all Pt provi ' he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER GASFITTER NAME L c,r I 5 : P,_e c1 e 1 l______1 LICENSE#_c5 _,1 S ATURE
MP 0 MGF-1 JP 0 JGF LPGI LI CORPORATION Li#1 i PARTNERSHIP[A#_________i LLC #
COMPANY NAME:I C c,r I I_ hi Cd e I_�_!' SO n,I ADDRESS 7 7 5. I"1 c,, in S t re e. _____._________ -_ I
CITY O 5 t-e r'v l \ I e - ---—.--- ..._____ STATE HA_ -aA ZIP o 5 5 TEL 50 S•- y a 5- - Cp 3 5_.CO ;,
FAX - I CELL- .. -- n-..'EMAIL -- — — -- — -- -
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