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' . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'_t t CITY �11, .ti.., +�--... . . I- MA DATE; 1 PERMIT#gi4b'7 .)W/Y
JOBSITE ADDRESS ^G.i ( #' OWNER'S NAME ' Tfa y )G w�(it.r+ .et y.�
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G OWNER ADDRESS. _�;.m.ek U _.._ ---------1
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TYPE OR OCCUPANCY TYPE COMMERCIAL A EDUCATIONAL 17 RESIDENTIAL X'
PRINT
CLEARLY NEW:;J RENOVATION::_Y REPLACEMENT:_ill PLANS SUBMITTED: YES J NO Li
APPLIANCES 7 FLOORS--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14—
BOILER _____1 ems,_ _ —J__! �__--1. - -_1;_—J `°___-J___1--I: L_�'.__i_
BOOSTER is 1 1, I r ��' t _fi[ .1 t r t__J____if
CONVERSION BURNER ___l - - I i . . 1._1 _ e I_=1--_ I ( __1, - -- I- .1
COOK STOVE ( I [ `_1_LLI_ I- k t ' t__I 1' -- I t
DIRECT VENT HEATER ._i—_J—J =J � _.( 1- _ _ _ J t-1 1. I— i- --1:�
DRYER' _ t -- t- i !- ._... j:_.. . .I, I_ ._..t_ k/ l .-..I—, �1- I__ I
ii FIREPLACE - ---�,•—J I —I J-.—J—1 ,. I ._-__:___1- - t — --I ___
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FRYOLATOR -- —i__-_If-.. ---- -..._.
hik; FURNACE
GENERATOR _ I .. . I. I I.._ . I I !__I] i I I • _`
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GRILLE _J' 1- 1 —J I !L_J—J. .I__J.—i _I___ I-L__._
4 INFRARED HEATER . _ I I. (_ . . - - -..
11 LA3ORATORY COCKS -_____.t_.—i' I I 1-______4 !• _I___1_.—i___'—J 1_____,
MAKEUP AIR UNIT ... . .t._. __1._j - - i-
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` OVEN - I I I i _ t i. I i --J ... `-----I . _ I _ I
lhk FOOL HEA►t ___.___I_____I__I I I ._.___J-------1 `•.__. ._�_1____I _.`.__ I J_—_I
ROOM/SPACE HEATER I I . .. . I I - - 1 . _. . 1.. I. I._- I ! . .._ 1 ! I . E
_ROOF TOP UNIT .J i r 1 _3 ! 1 4 I i . f ;_._-1�_j
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' J i i -_! ' I I- _..I____ ' I i I t I
UNIT HEATER I I 1 • I 1_1 _ I , f I ..L _ .1
U'NVENTED ROOM HEATER • __� 1-__1-_1
1- 1 - I . ._. __I^J_J--_,-J I, J-_____i____.J
/,TER HEATER - - -- -' I—I�J I I_J ; 1 ___J__J i f .f i
OTHER= I. -.1, - . .. 1 ji _ I I
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44 INSURANCE COVERAGE
°1, I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I_(NO 7
pip, I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW
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LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 1-_-1 BOND U
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
__ SIGNATURE OF OWNER OR AGENT
1 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 co pliance ' all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _
PLUMBER-GASFI I I ER NAME i /-7G.—~ass/2,�c� 1 LICENSE#fa'�cj - SIGNATURE
MF✓ MGF L JP J JGF'_f LPGI 11]- CORPORATION Li# / E PARTNERSHIP''#' -1 LLC:_j#: - 1
C�44 �� � -i - - -- J , 5 - E
COMPANY NAME:. fi �V 1 ADDRESS: �i'r-- �/�/l�
CITY _ ...9-/Zdifc,c9 - I. STATE: P 0;2---4 ci TEL , 7 -- -----FKX ._ .- . i CELL _I EMAIL:- ..... .___1
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