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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY yA f JY MA DATE a 7PERMIT# LOh'/7 /
JOBSITE ADDRESS l_kN Rd1 7:7-7,,... OWNER'S NAME P e--(A— re,,5A/t c)
GOWNER ADDRESS ', J TEL L 17 t-7 7 1✓ FAX _
TYPE OR OCCUPANCY TYPE COMMERCIAL(��J EDUCATIONAL RESIDENTIAL t
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNITeii\- ..1-1.-
OVEN C 0 cfp
POOL HEATER L.
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER _..__-� ----
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND
OWNER'S I NCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass usetts Gen al Laws,and that my signature on this permit application waives this requirement.
t CHECK ONE ONLY: OWNER AGENT
ATURE OF NER R 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 Perti on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 3 f livitt %/I; I,'1,9 tirh L LICENSE#v 2&z/4, SIGNATURE
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MP MGF JP JGF _ LLC #LPG' CORPORATION # PARTNERSHIP # —.n.—__
COMPANY NAME: b /1 v„r 11.</►tit_ ADDRESS (a C..c./e it yI t.- i
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CITY \(•.0 v o 11"i, Qa rf- -- r, . STATE /ttk ZIP OQ(, 7 S TEL 3?s r 776 6 76 Z
FAX! i CELL — _._.-:EMAIL 1.«_y _ P- �2 h7C.D el/i7-7 2t-A47v '.C. m
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