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1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FIT`-I"1G WORK
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JOBSITE ADDRESS L
TJ Q 94 OWNER'S NAME•.' !%
OWNER ADDRESS R'.-....-_..__,�� TEL ...,.......,, jFAxJ rI
TYPE OR OCCUPANCY TYPE COMMERCIAL"s.-! �Vy w
PRINTI EDUCATIONAL 1....1 RESIDENTIALIiy_
CLEARLY NEW: RENOVATION:E,1 REPLACEMENT: PLANS SUBMITTED: YES`___I k___Ii NO-11
APPLIANCES I. FLOORS-4- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER , I ' I f
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BOOSTER L. '' 1 I " � ;1—i I ,I'— hI isf
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CONVERSION BURNER i___._,-_ril__-.-11l_-!' ,-_,II._.--_I L._.___I___�I'~..,. `;r ___tti_.___._;,11- l ___'.--_JAL__ -
COOK STOVE -T' 1 i.. I I .,..._-.-'�`--°! _ „ I ;! . _ i
DIRECT VENT HEATER '- '. = '� : . 1I ` -'i
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FIREPLACE -- IT- j ;
FRYOLATOR __- -
FURNACE :77.! =' '-� -
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GENERATOR
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GRILLE . jiln = ) F ,INFRARED HEATER di li 1 i ,'•' !id !' ill
LABORATORY COCKS ''I ;I--- �'�-1.7--=pit --
MAKEUP AIR UNIT , _ly i. -._-- :Al :�.- • .ji._ _.'_._.. i,_ !iI__ h._-_ -
OVEN '• I I!L li,.II IL_-__-, :I it li' r!i .i
POOL HEATER I:: .i-----71— ! :?- I ;�-_-� '----.-... _ ..__ II_.._.._
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ROOM/SPACE HEATER y yl;_..._-rl_..__.J�.----- a,..._ + L 'il--
ROOF TOP UNIT !I -!?,._._-.I.I.—_II_-__..I11--1I__.____;:_.._ :;__ '1-..^;Ir.._.. ..i4iti 3i _
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TEST r- I --i T._._. 11—> �_ 1�_ r .-„ t_ .-_:1._. 'I—
UNIT HEATER .-_ _
t: .; ., �1 __: :�.... ll 'I-- '--__....- --._ ! ..._lit_ .!L__..._I_.__._
UNVENTED ROOM HEATER :` l __- _, — :F_— fi ___ ,
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WATER HEATER i_..,._,.,��..,,,--_E i_�.._ i _I!I. __.....,;,------_'_ , ;
OTHER li
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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 LINO L I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I. ii OTHER TYPE INDEMNITY`si_u. BOND ......1
OWNER'S INSURANCE WAIVER:lam 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 (_.
SIGNATURE OF OWNER OR AGENT
t 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l) i
PLUMBER-GASF1TTER NAME LCrai Bisho I'LICENSE#115101 SIGNATURE
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I I.PARTNERSHIP NERSHIP
MP�' MGF I. _� JP� JGF�; LPG[ !� CORPORATION I._-;l�iR s,..j# ._. ,,.._.,is LLC T 1#L...,,,_.-__.,.,.-_.`i
COMPANY NAME:illgh Efficiency U ADDRESS 1 378 route 130 f!
CITY .Sandwich 1 STATE f Ma 'ZIP I02563 TEL
FAX;_.......__............._..._e CELLI! JEMAILgadmin a(�high-efficiencyllc.com li