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✓/__ ._. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY _- .1C C _.n,C .a4cY _._.._�._.____..�_._._
r 1 MA DATE AO 7_ %1. V J PERMIT#*D&R-Cra A
JOBSITE ADDRESS{. ,Q__AC._ .._.-ACx .. e..-_...-!OWNER'S NAME ;._.Mc cAeG.`( _______...._________
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TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL P11 RESIDENTIAL]
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CLEARLY NEW:0 RENOVATION:I0 REPLACEMENT:a PLANS SUBMITTED: YES NO0
APPLIANCES 1.. FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ,�_« tL.,_..- _1 _ __11��Y ; -. _ I!.,___ ` ,t Ei L 1 _t
BOOSTER s.__:I 1 --- II-- --31 --..f.� I I.. . 1 _ .Jt�_. t
CONVERSION BURNER ( I_._=i ! ! _I __�;!. l t' _ TII tl _'{
COOK STOVE :_ .... --_.... `.1_--___I - - ti __ . 3' I .._... rii gi A,_ IL . `L_.- .._ 1 ...__a ._..._E
DIRECT VENT HEATER -_.. i- 1 II =i__ -=!____1 I _._ I_-.. ' __-i =i___-_ _ i_-�4
DRYER 2.
FIREPLACE
"FRYOLATOR !_ I ! 'L._ •t:_. .?..,: 'i:. --;1,_ ) l__ JI l„_.-_11
FURNACE L T
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GENERATOR �:_, Y t 5 -_; . _ ^____ LT _!. y_J ___
GRILLE i r II„ _... I _11 11 I 'L.._�_ S ._... 1._ _ F ,..
INFRARED HEATER
LABORATORY COCKS Li
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MAKEUP AIR UNIT =i I I C1 i.
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OVEN i. : _ _,..._. _ i:,._ ..- t_._
POOL HEATER _ _ -
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ROOM/SPACE HEATER 1__ _ ,I .. .7__ 1! .l ----- 1_•__ I
ROOF TOP UNIT I
TEST i °L_.z,.,i: I, I s1 i 1.
UNIT HEATER I 1 -I `I 51. f— —dI— I
UNVENTED ROOM HEATER 1_ li .. =i� `' L T __
WATER HEATER T '
OTHER I -__ _ 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 NO ,J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY aOTHER TYPE INDEMNITY -_...-I BOND
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 1_,A AGENT L__..
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 'aept provis• e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I C r✓,r I_-5 ,— R; e cl e 11_ _I LICENSE#I-- yG f S ATURE
MP f,A, MGF JP 111 JGF LPG' CORPORATION II# PARTNERSHIP( # d LLC Flit1
COMPANY NAME: C c,r I 1- . R;±d C 1 L. r.tson I ADDRESS -7.77 5'_—M c. r� _S t re e t _ _ _ __—_a
CITY I_ O S t e c v i I I C __ ._..—_--_..._..----------___._-1 STATE M A :ZIP P I_O a Co 5 5 TEL _.5 O�s_ H a _Sy 3Co- .._
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