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� 8UASSACMUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�.]� OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL Fl RESIDENTIAL��
PRINT ^�
CLEARLY ��~�
NEW: RENOVATION: �� REPLACEMENT: 0 PLANS SUBMITTED: YES El NO
APPLIANCES-1 FLOORS-~ B8w 1 2 3 4 5 5 7 8 S 18 11 12 13 JA
BOILER |
----_�
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE |
FBY0LAT0R |
FURNACE
GENERATOR
GRILLE |
INFRARED HEATER !
LABORATORY COCKS
MAKEUP AIR UNIT |
/
OVEN
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER -~
UNVENTED ROOM HEATER
WATER HEATER
OTHER !
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INSURANCE COVERAGE
|have o current liability insurance policy nr its substantial equivalent which meets the requirements ofMQL Ch.142 YES [k-NOE]
\|F YOU CHECKED YES,PLEASE INDICATE THE TYPE OFC� BY CHECKING THE APPROP�AJEBOX BELOW
LIABILITY INSURANCE POLICY ��- OTHER TYPE INDEMNITY F-1 BOND 71
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 E] AGENT F-1
SIGNATURE UF OWNER ORAGENT
I hereby certify that all of the details and information I have submitted or entered regarding thisn u true and acc ate to theof my knoWedge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance all Pertinenti the !
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
PLUMBER'GASF|TTERNAME L|CENSE��m0� -~ ~--~~ RE -- ~
MP 7 M8FEI JP��GF El LPG| [I CORPORATION[I# PARTNERSHIP Ej# LLC[]#
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COMPANY NAME ADDRESS
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CITY v"�c-r-��i�� \ STATE � ^��� ZIP 0 � � Y"�' TEL -- `��4'/'7
FAX CELL EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
6/25 C>/Z L/&Gf /sio0 Yes No
THIS APPLICATION SERVES AS THE PERMIT L
FEE: $ PERMIT#
PLAN REVIEW NOTES