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/ �� ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORN
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NA DATE �SJUD8)TEAODRE08 '9___� ��� r O �GWSNA �
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"�m OWNER -� �k����____./TG F��[~�~~~.~.~..~}
TYPE OR OCCUPANCY TYPE COMMERC|AL�l EDUCATIONAL R�8iOENTk4LD]-~-- - �--
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CLEARLY NEVV:Fl RENOVATION:�r -^� REPLACEMENT:[AL PLANSSUBWITTEO: YES[,.,( NOFl
BOILER 1,
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYCLATOR
FURNACE
GENERATOR J%j
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN i
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 5
OTHERI
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES F/,J.NCr[-_]
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY F7]~�~ OTHER B�NO [-1
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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 INS requirement,
CHECK ONE ONLY: OWNERF—j AGENT �l
SIGNATURE OF OWNER ORAGENT
/hereby certify that allof the details andInformation I have submitted or entered regardIng thisapplication d ^mohnyknv�ndno
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'__--------__ �_ /17'PLUM8ER��ASF|TT6RNAME L|�EN8E# � '/ SIGNATURE
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