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.S MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITYITownof y11 ��Oclip. MA DATE'_ - PERMfT# (flb-I' oO3(y ,c
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• JOBSfTE ADDRESS! _1L65
le rstr,e--_ :OWNER'S NAME ! ,�r PrA S KI
GOWNER ADDRESS ( ._ o))77 I-DO aliFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL Eg EDUCATIONAL RESIDENTIAL,'!#
PRINT
CLEARLY r— �` r^
NEW:ems RENOVATION: f REPLACEMENT: PLANS SUBMITTED: YES' NOLI
APPLIANCES Z FLOORS-+ BSM 1 2 3 4 15 6 7 • 8 9 10 11 12 13 14
BOILER - -. t,! .. f t 0 k a ____ !_� z^ _ -
BOOSTER ;z A- ._ ` _ �: _'
CONVERSION BURNER -Si _y _ ' '�' _L i_ _, i __a __V 1 f__—
COOK STOVE - a .m -`- �--- ,-
ree,.-r. _ 5.-6 '..� .-,z-.V— ._
DIRECT.VENT HEATER _ r ii 1, J',_-_-_- L . I ! ill - g----
DRYER I— i t V�_T - 1I ��i I_ __ _ (_,—l.._ iq
FIREPLACE =' i ! I _ 1 I
FRYOLATOR 1 - J iL. 0 J .__C_ 'ei . .._:.________1_
FURNACE :_ EMA �. r__L -L_.•-_.. II _ ,i , _
GENERATOR , _ '_ _.
GRILLE — E _. .4 ; _
INFRARED HEA I Eli i._ -' t.._ ,i - — " _ :APE- _ I rani__
LABORATORY COCKS I - •1, ' ' g" '1 '' '
MAKEUP AIR UNIT 1.111.1.1. _ ---tl -=+__ Y• _'i ' '_._ � ,°
OVEN :._ .;r ' ,I1S{Lg,,,l1 W,:,.
POOL HEATER ' �`. iI 'NMI _ _ E.- F. -.,: _� ;: :ga L •
ROOM/SPACE HEATER + T ' y k . Ii-_ _ ' �'. _
ROOF TOP UNIT • ` _. * - II_A —t _ •_ A� ;i---
1--
TEST - _._-_ice.._-
UNIT HEATER i . 0 01______0_- --- J f_- _---! , L_._ t_,-.--!
UNVENTED ROOM HEATER t_ ,�1 P _.._ �_ i ! ._: _it :; '
WATER NEATER _l_a'_.- A---. - -
OTHER j L_w=��.--s��: �a s �. -. �..
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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
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE INDEMNITY O. BOND 0
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 (, AGENT C]
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 e t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance ' 0 nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFI I I ER NAME n {{.�l P , i,LICENSE# I I----9O° SIGNATURE
MP Zr MGF 0 JP C] JGF] LPG!J CORPORATION Ed#;a 8 6g G 1 PARTNERSHIP (LLC Litt, i
COMPANY NAME r,-rnc'Bf;C)B PiuM-} ]-.r 5.mc ADDRESS i T P 1
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CfTY I W. Vc.r.rr :.41,‘ • , STATE MZIPI Q L.73 1TE4(56 7/g- 4656 3 -
FAY r,,),,-,-h7k51 CELL IEMAILI _ I
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