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MASSACHUSET T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FIT--I 9G WORK
- _ CITY 44u =# F4v '! MA 40 i ! C�� ii�IAt,._jPERMIT* _ ` �0 7
JOBSITEADDRESS - oaf 1,11SWNER'S NAME"
OWNER ADDRESS ° J,,99t Ate!_. _21
TYPE OR '
OCCUPANCYTYPE COMMERCIAL ,-I ED ATIONAL�J RESIDENT! •
PRINTCLEARLY NEW:; .' RENOVATION:fl REPLACEMENT:' .PLANS SUBMITTED: Y ES LI NO[1
APPLIANCES 1. FLOORS-,. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER .,;-: %I__.._.., --1 _- _ .._.
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BOOSTER ' �l �, ar--I -..._ iit I _ ... _ _
CONVERSION BURNER i____,.. l_.--- C- J-_ IL .__i��' iti _ _.___''F. 5_ -!1' `L.
COOK STOVE --__J( _a -.! i,=I,. _ a^-`' _ '• -. 'I iI { - is-_�?i _:
DIRECT VENT HEATER ---__I__-. 1-)-�� - .._.... . .1�- .._....•__-_ _
DRYER _i =1- I 'Il _...�, i _ _I I -_ti -fI7-7
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FIREPLACE i_._ _n - Ii __a l__._ i l_ ..!�--1___..._l . __-I._ 'I__..-_l i _
FRYOLATOR __~ rr--- - Y: _-- i l
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FURNACE :.___.2 I-----:1,`._—',_ '�1-----=�-•----'s'- _:L___ ''-_.`ik_---fir-- = nd- '?'
GENERATOR j-_-- - 3______1.I_-? ..__..... - IIL_. _`'I 'y.._._._I-__,_I!. 1- -- �w_-, .
GRILLE _i__ _.1{1 nL�;l___. I ____i?--_..F._- _ii i__._ 1:.____-`r _-'l --- 1 --
INFRARED HEATER II, f I 'S` 1 11- 1-''1�'' _-- __ _ - ra ' = r _
LABORATORY COCKS ?I L . -�i- — 1- P .._ii -�+'11-__J i. i`_..._-`t=_i l 1 -
MAKEUP AIR UNIT _`', _ It` 1 iili _ -F_a.____._i_._.—._i?-'•.. _-_.l,_-__'_._..._i _ ':1 3__
OVEN 1---IiL_- '1� -_.,j Jl{_____)---.1i-_-_-. ,._-JAL.__.. ;I ;ice i;'__;L i !
POOL HEATER i---- :I . ,! ,I- (_-1- 1- '' �- - 1 -
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ROOM I SPACE HEATER • -- _ ; ---;, �,. , -----'_____..- "I ,_ - 1
ROOF TOP UNIT l - l I. '•!I I I_ __11"�T�_ i-_.. Y' 1.___'r 11 `r':1__-l
TEST 1 l_-_ ; 1177.21- I --•- -•-- -- 1 __=1
UNIT HEATER P ?1___,_.3ii-' I'' `'I -�-- - -- _ ''I-_. 'i_. '
UNVENTED ROOM HEATER I- I-- -
WATER HEATER i_.._._,..„_ • �.: -: ._.{,�-,-�_ =y„�._
OTHER I II L_._l L----._'i 1„____=- i� I_._._.-'1----.ii- :II-._----:�_. 1 i ^i_-_ -=''- ')
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t „ ,_._ o, .... _._...__il INSURANCE COVERAGE -~
I have a current Viability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ,,L NO l I
l IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY -iI OTHER TYPE INDEMNITYP. BOND L.....I
OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage required by Chapter 142 o`the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER L_ AGENT [___II
•
SIGNATURE OF OWNER OR AGENT
t 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 pi cvision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C.. < I)
PLUMBER-GASFITTER NAME LICrai Bisho I.LICENSE#15101 i J SIGNATURE-
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MGF L JP Il 't JGF 7 LPGI LJ CORPORATION ,•]#3 <, �1.PARTNERSHIP j# II LLC a#4
I ADDRESS 1378 route 130
COMPANY NAMEHi h Efficiency J
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CITY tSand'Mch I STATE Ma iZIP;02563 i7EL''�,--_ __•._..,.._•._.u_-
FAX ....._- CELLII JEMAIL admin�high-efficiencyllc.com G
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