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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS H z al ( tnj_ (iitU I OWNER'S NAME Pouti_c 1
G• OWNER ADDRESS TEL FAX __ w
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1_1_1 RESIDENTIAL
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CLEARLY NEW:Lj RENOVATION:0 REPLACEMENT: "4 PLANS SUBMITTED: YES0 NOD
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER 'I__ , ___,J.I II L' I -_, 11� �l1u `I r1
CONVERSION BURNER - :_______II�__� •3 _,N__I� -�-�'1I !___2 iI._-.._ ( 1-__� _ _1, .. , __.._
COOK STOVE
DIRECT VENT HEATER l___._. .Il_.. ___.:'L._.__ I___.__._.-i. ._.-. 3 ___I•.. a`.__..._..4
DRYER 1 yYrY I i ; (.,_ _ RI__ .._
FIREPLACE s' - -
FRYOLATOR I ! 1 'I I_ _ =..3 ._.._
FURNACE
GENERATOR i
GRILLE _:..- s,...-- ._._Yy1 __... l._- 4--_, ,_ _ L---'
INFRARED HEATER :I_.._ ! 3 1..- ... . !. . !,
LABORATORY COCKS _
MAKEUP AIR UNIT r—. I._ _- I
v, .�f a p F 3
OVEN W I....:_.___..: _ _ ;I,,._._ I _ (__ ...1
POOL HEATER _
ROOM(SPACE HEATER i_ . I I_:T J.
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ROOF TOP UNIT I ..., I :E '
TEST1....yy,y _ .:..
UNIT HEATER I,..__ i iY .I__. 1-
UNVENTED ROOM HEATER .__-: ' '.._ 1..T_- -----
WATER HEATER I_-_': —._ ' _. C.._ '
OTHER .._._. :' I
Mill
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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 4NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW •
LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY Li BOND __I
•
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 L,,,_ AGENT 0
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 Pe t provis' he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — �. ,
PLUMBER-GASFITTER NAME _�c,r I -S ._ [ __e d e_I 1 --_____ LICENSE#--8 61 S ATURE
MP 0 MGF E JP EJ JGF C] LPG' CORPORATION LJ#i ,_r..i PARTNERSHIP[#I _. _t LLC,1#.^________I
COMPANY NAME: C c,r l 1=. R_LeAf L_.I__t_._Sa n_I ADDRESS -7 7 6 I"I o __ . Scree k T�.._-.�.__
_US_t_e rYv!_..l_�.._e...__ -_._..-.. STATE _MA... ZIP'.._,_UaG5 5_.-,TEL _5U.�s._-`�{d s- _Cv 3.Co 5___
CITY _
FAX __.._.. -_. CELL IEMAIL____ _._._..._.._._,..___...,____.__-__..Y__..__- _.--- --.____________....,__.__.___._____.-.-.._______..............._........_.-_._