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• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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a= _: CITY 47.r 1146111 t MA DATE 11/-o7 1 PERMIT# 111-' c&- z i- 2&9
JOBSITE ADDRESS II( 7i),"T/ T oaf: Ai !OWNER'S NAME �� t,l.-_ C, 1-i_, ...1
GOWNER ADDRESS $4 toz I TEL. gJO3, 6(44 I FAX
TYPE OR OCCUPANCY TYPE COMMERCIALLi EDUCATIONAL 0 RESIDENTIAL®
PRINT
CLEARLY NEW:El RENOVATION:0 REPLACEMENT:jig PLANS SUBMITTED: YES Li NO
APPLIANCES-1 FLOORS-4 BSM 1 2 3 4 5 6 7 8V 9 10 11 12 13 14
BOILER 1-----,�;
BOOSTER i
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CONVERSION BURNER _ =ir:int-- = 11 ,
COOK STOVE i:, (-
DIRECT VENT HEATER ilitlillt
DRYER
FIREPLACE
FRYOLATOR01.11101111111. '
FURNACE ), 3 W C�
GENERATOR � I '
GRILLE ® a
INFRARED HEATER ___ .
LABORATORY COCKSil ®._.�_.
MAKEUP AIR UNIT __ I '
OVEN
POOL HEATER i�i
=SE ad
ROOM I SPACE HEATER
ROOF TOP UNIT
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TEST r : IT,
UNIT HEATER _ 1 F
UNVENTED ROOM HEATER MI ( N M ®61, '
WATER HEATER i } J� -
OTHER M n i ,._ - ° ' I .1: 1-.
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INSURANCE-COVERAGE
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CE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 2 NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I_ I OTHER TYPE INDEMNITY in BOND El
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 0 AGENT E
SIGNATURE OF OWNER OR 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 compl' nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME OA/c 0 _ I//1-h/ NO iii t LICENSE#//d 9A SI TURE
MP El MGF El JP® JGF Q LPGI Q CORPORATION 0# PARTNERSHIP 0#, - LLC Q# . -
COMPANY NAME: V-j /� At_O r 144,-/u ed.!-f ADDRESS </0 (� /i4 4 2 .44.-wcd
CITY _12, 1,=' .i4,..c.-.. ....... STATE yard I ZIP el-6 ?�.:TEL_ ¢.74? 9•if1 _.?"7 I
FAX .,. __.._._ ._ _._I CELL,._ .. .... __.. _ _. EMAIL '- . � -n.L 4...xdd �o C Gh2s4-/_(.e ern, L