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' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-r_7.-pit=L7r"�_ CITY r MA DATE` I PERMIT# i fi'100/An
JOBSITE ADDR SS � OWNER'S NAME
GOWNER ADDRESS TEI AX,
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL izi RESIDENTIAL14
PRINT
CLEARLY NEW:Li RENOVATION:LI REPLACEMENT:x PLANS SUBMITTED: YES Li NO
APPLIANCES 1 FLOORS-+ BfSM 1 2 3 4 5 6 I 7 8 9 10 11 12 13 14
BOILER
4
BOOSTER
CONVERSION BURNER �L. �..,.. I i 1
COOK STOVE
DIRECT VENT HEATER -
DRYER xau�.�,
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
max.
POOL HEATER ,
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER°.
OTHER _ i .,
_ �_,„ __ ..
_,____,
,.
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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 X'X'NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X OTHER TYPE INDEMNITY 1.„,j, 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 Li AGENT Li
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 sac allttsSt plumbing work andininstallations performedpterunder the permit issued for this application will be in cornwith all Pertinent provisionof the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ---frt/�,
PLUMBER-GASFITTER NAME Y 1 LICENSE JP-(5 Q SIGNATURE
MP X MGF JP JGF Li LPGI 3 CORPORATION' ti# wW PARTNERSHIP # LLC. #t
COMPANY NAME W, Vernon \J 1 1 - ADDRESS Vi I(Qq ��X III
CITY Lo. 0.1�10�`i•`�'1Q1,� STATE11;A ZIP ��JvnI TEL �I1�°C}- 10�
FAX' CELL EMAIL!
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
1