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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t. --1:i— CITY UU MA DATE: �� PERMIT# d1��r'� �
JOBSITEADDRESS1 , 1 1 UELOSA .'r L OWNER'S NAME j 10.. .l. ;d ..._. :G ;
OWNER ADDRESS ( - r� ' ,, IIFAX 1
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TYPE OR OCCUPANCY TYPE COMMERCIAL ; EDUCATIONAL LL1 RESIDENTIAL LT
PRINT
CLEARLY NEW Li RENOVATION:1[] REPLACEMENT:in PLANS SUBMITTED: YES,._,, NO
APPLIANCES 1 FLOORS—I BSM ' 1 2 3 4 I 5 6 { 7 8 9 10 11 12 13 14
BOILER —_ - ri i r
BOOSTER �l d. ill i.... ri I I
CONVERSION BURNER
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COOK STOVE l— 1 1 s, � 4 ., e L _ ce axis
DIRECT VENT HEATER 'i I ;I :` y e
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DRYER
FIREPLACE Ir_..» , L...... : ... ". , _
FRYOLATOR L....... . (— I �_.._ L...rt . l 1 1
FURNACE ^r r +....... �.
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GENERATOR 1-_..._... 1' 1
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GRILLE I -? _. ,1,,.. 1......._.:N .... _._;,.... I'� ii
INFRARED HEATER "—�
LABORATORY COCKS .__
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...ter ( �
MAKEUP AIR UNIT r— it '
OVEN .11,...„
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(1 1, ,.., „if I,... . 1 ,,. ._.._ i ..,..., ! I =.
POOL HEATER 1—
ROOM 1 SPACE HEATER ��r is ' t 1i
1, 1� -_..,C "
ROOF TOP UNIT :!._:... .. _._ I ;_
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TEST '' :11 7. !
UNIT HEATER J ...... I (,_..._...,.._ •a _'1 iI.. 1
UNVENTED ROOM HEATER I ti rs 'L�.. I ._ 1 _.. s
WATER HEATER rt..af� .:G I,. C „�^
OTHER I ..L_..._L1. ,.. .':� ..-.._.1..._.. .LT. -. '; .-1,,,,, _ , ..__.. l..
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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 tz," NO ri
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I,;,1, OTHER TYPE INDEMNITY '71 BOND L,,,;,;;
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.,.0 AGENT
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Cili ^ 7
PLUMBER-GASFITTER NAME'Crai BishopLICENSE#15,101 l [,/ SIGNATURE
MP= MGF 1.. , JP ,, j JGF PT LPGILT= CORPORATION I_J# 1 PARTNERSHIP, # LLC 71#
COMPANY NAME:Hi h Efficiency U ADDRESS 378? route 130 1,
CITY `Sandwich i STATE Ma ZIP102563 TEL
FAX ,..__._.. w....._.,._ua CELL L__ i EMAIL'admina9hi9h-efficiencyllc.com _. ... Ii
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