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MASSACHUSETTSU O C |ONFORAPERK8|TTOPERFORM GAS FITTING WORK
W.
CITY MA DATE PERMIT#
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� n� OWNER TEJ �FAX �
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TYPE OR / --
0CCUPANCYTYPE C8MMERC�L U EDUCATIONAL | 1 RES0E
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CLEARLY NEW: RENOVATION:RENOVAT0N:F-3 REPLACEMENT PLANS SUBMITTED: YES[] N0[]
APPLIANCES I FLOORS- asm l 2 3 4 5 o 7 u y 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER [ _ \ I
COOK STOVE
DIRECT VENT HEATER [___� [___�| U
DRYER
...~.`.~.` ..........
_'.___
FURNACE
GENERATOR
GRILLE ..._........
INFRARED HEATER
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LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM SPACE HEATER
ROOF TOP UNIT
UNIT HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO E]
iIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ����� OTHER TYPE|NDEMNIT ��Y �� BONDF-�
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 ElAGENT [D
! SIGNATURE OF OWNER ORAGENT
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 mmyknowledge
and that all plumbing work and installations perforrned under the permit issued for this applicationwill ma/ o
Massachusetts State Plumbing Code and Chapter 14cof the General Laws.
PLUMB ER'GASFITTERNAME � L|CENSE���� S��RE
MP�7� �GF� ] ]PF-� ]�F-� LP�|-� CORPORATION XPARTNERSH|PF-�# ' LLC��#| �
4�� -~ �� --� �� --- -- -� ^�° ' ' �� /------'
COMPANY NAME: ��|_ n_)ADDREB| ��
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CITY _[]stcx-,/ � Ut� ��
' 3TATEI�P
FAX _ | CELL_ JEMAL ___ _________________________________ �
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