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‘s.\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESSE:1,..,122 j„.0.22,: _,,,,,_.I OWNER'S NAME LL,,,,,,:„.,1
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TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL 0 RESIDENTIAL GT,
PRINT
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I RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YESEI NOLJ
APPLIANCES'I FLOORS-1 (36m 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER E
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BOOSTER r -,-17T - 7 ' r-- 1 1 1 1,1 11 11 li .r .
CONVERSION BURNER
COOK STOVE --z.„',114:•4,-,K.:-IL.::.Jr- - --I• • I -• I - ., . II-- II- • .1 ---..,1- ,-.-•ii,-J•5.....,--,&!;,-.....,tf1
DIRECT VENT HEATER
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DRYER
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' FRYOLATOR
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,GENERATOR
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INFRARED HEATER i I L: Tina[77.--i---'-',Ift-‘11-L91 1-A---1 r--- --ti----C-- ii—ii tr :-.. 1--.. 1
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LABORATORY COCKS fi--- „AK.. ._ . ,..,.i 1-.1111.110111.111111:T, 1 lint--7....,
MAKEUP AIR UNIT
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POOL HEATER
ROOM/SPACE HEATER II r.: 11 .--1T- i- II ,IC. il.,., if „ ti 1 i,. IL if,.'t,..„-ir.„ .,-1
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ROOF TOP UNIT 1..=,..=:,J .t.:...-.11=,...11%--_- :1,..11,-. k. ,.={111I LI 1:.,. ..,}C , z-:;.11-z.. , ,f 1,2. I l:,:„.1
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UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER ' - 1r flr . IT 1- J i _ 11 1,. ,.3-„ ..i.„
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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 12iNCr0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Re- OTHER TYPE INDEMNITY ET] 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 L--,,J AGENT El
SIGNATURE OF OWNER OR AGENT .,--.,
I hereby certify that all of the details and information I have submitted or entered regarding this application are IrrInd accLfratito the best of my knowledge
and that all plumbing work and Installations perfomied under the permit issued for this application will be in complOinpe w fh alpPertinent provision of the
Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. ,(.. ./ . .i
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PLUMBER-GASFITTER NAME L ......4. i„,.c..„,,s',.,,:.,,,p ]LICENSE#1,11/20"' if 6 • SIGNATURE
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MP/IXI MGF L.J JP El JGF El !Pei El CORPORATIONE/PC'
•11:2,21;2, PARTNERSHIP j_ 0 CT1 LLC ...................
COMPANY NAME:LC)4 Z - fr ,7-. '' ij DDRESS1 e R aii,i6thi icall„, 4„-s,4,\.,A_._...,,,.\Ftfuttz-Lk\,A
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