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. _ - MASSACHUSE I I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY I Town of `/A QM() 1-N i MA DATEL74—p PERifT#fr-iat sl 7-00 J(PG 5-
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JOBSITE ADDRESS!. I I `LQ .�OWN R'S NAME F .()di, C nn�rna� a
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OWNER ADDRESS I .1TE(20I qz- -00C,C) IFAXI _
TYPE OR OCCUPANCY TYPE COMMERCIAL 1= EDUCATIONAL LI RESIDENTIAL
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CLEARLY NEW:j RENOVATION:'I i REPLACEMENT:0 PLANS SUBMITTED: YESLI NO:_____I
APPLIANCES-1 FLOORS BSM 1 2 I 3 4 5 6 7 - 8 9 10 11 12 13 14
BOILER - I_4 a _ - 1 1
BOOSTER _ :�! �- "�L^_- �.,. lI C $ 5
CONVERSION BURNER 'y�J �_.i _ r 1+ j
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COOK STOVE l M -- -�._. __ J' ;
DIRECT VENTHEATER W _ '
DRYER =-_— ! -- 'i 1, I • ,, :; ,' ,:
FIREPLACE IIIII-1_ : '1 _ : .' 1 __
_
FRYOLATOR - ', — ___ 3, — '.. j—. .
FURNACE 11 'I -- �—_-- '
GENERATOR 111111EW - .' I -L__ i
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GRII I F _MA_ 1_ IIa' . - ......4',...___.:'
INFRARED HEA I ER - _ :I_ _ I
LABORATORY COCKS - - 1LL'jl^ • -L` ,• ', .1 :. �_
MAKEUP AIR UNIT M __ ' '•_ r ' • 11 .�__•9:-' to c
OVEN -.W. ,�,liqu aILL- .1L�WL;-_-___I
POOL HEATER '_ .-----_i___ __ 'NM - =- - l _, 4 _ •, L _
ROOM/SPACE HEA I ER WO ' _ __ ;,,�,, "ita"li' -- _ 4
' - ,
TEST , - ': i "'
ROOF TOP UNIT '
UNIT HEATER _ ' 1 ____I
UNVENTED ROOM HEAL LR :___.-1.�, 1 --:'- -. -I -_ 11111111111'_ ice` --
WA I ER HEATER -- 4 - - L. - "
OTHER
INSURANCE COVERAGE
I have a current Iiability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES eN0 I9
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1..1•!e OTHER TYPE INDEMNITY 9 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 D AGENT ri
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 pe best of my knowledge
and that all plumbing work and installations performed under the pemift issued for this application will be in compliance all p ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFI I I ER NAME pV r, fl)(-B r.t P a _ !LICENSE 11 b 0? - _ - - SIGNATURE
MP MGF 0 JP EI JGF 9 LPG' CORPORATION I f#id 8� .C. I PARTNERSHIP 04 L L C EJ# i
COMPANY NAME n(Y)' r;(L. ')EL?, t '- z ADDRESS I I (,-,.J p4A 1 3
• CITY W. `/r•rrrn:.-}'I - i STATE 1M ZIP (3)-673 1TEL /5o ri ?7F- 4 5- i -
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