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RECEIVED
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Hui.DI-f/-'f=`,.1 RTn r iQ//lKUvr`f /\ ��ATE: 72�PERMR#a o_v-2f—327
JOBSITE ADDRESS:�7 V.Oil(( A L OWNER'S(N/IE: /t I'v .l(/L /V aN
G OWNER ADDRESS: CaAi)% TEL�/!O(1Q a( AX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
APPLIANCES) FLOOR—. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR _
GRILLE
VI INFRARED HEATER
LABORATORY COCK
k MAKEUPAIRUNIT _
O OVEN
POOL HEATER
ROOM I SPACE HEATER
J ROOF TOP UNIT '
2 TEST
.Z' UNIT HEATER
i j UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES(ENO 0
Ifyou have checked IF.„5,please indicate the type of coverage y checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY❑ 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this eppication are true and accurate to the best of
Knowledge and that all plumbing work and installations performed under the permit Issued for tNs application will be In ptl II e
provision of the Massachusetts State,P(/thl Co" ndjChhaanter 142 of the General Laws. /
PLUMBER/GASFITTER NAME: /U 0 p2!`� /"l Uit/J Q LICENSE#)�tP/R IG TURF
COMPANYt�,A�E. Sa.-. ADDRESS: •
CI : J,Y/i- 0 V q STATE: , ZIP:A?6 73 FAX
g70 8"3 t CELL: EMAIL: id-to Ivey'Sr Ut/I-O 1923 0 6-Mair CG 1'1-
MASTER 0 JOURNEYMAN 0 LP INSTALLER(?." CORPORATION 0# PARTNERSHIP❑# LLC❑#
EMhYL ADDZoSS:
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES