Bldg-20-000066 f " MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1
o r MA DATE L' 3" ) 1 PERMIT# !3"" Q9cP4
e. ;;• CITY varr►�uv- t P -�
4i Anoc 5e� teed,
JOBSITE ADDRESS 10 $ -v`et_J,ard L i OWNERS NAME Ct ,M4e- )t sad
OWNER ADDRESS Sct_*-4"4— TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL
PRINT
t ❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: V PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--‘ BSM 1 2 3 4 5 6 7
_ 8 9 1 Q '11 12 '13 1
BOILER
BOOSTER •
-
CONVERSION BURNER
COOK STOVE •
DIRECT VENT HEATER
DRYER i
FIREPLACE 1
FRYDLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER j
LABORATORY COCKS _ _.__.. . �___.- -- i i
MAKEUP AIR UNIT .
OVEN
POOL HEATER • 2'91
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST -
UNIT HEATER ___.__,_=_,_ i_._....
UNVENTED ROOM HEATER
WATER HEATER
OTHER
•
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ej 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 ❑
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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 this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 ac urate to the best of my knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in compiia tth all Pertinent pro ' ion of the
Massachusetts State Plumbing Code and Chapter'ILt2 of the General Laws. /n`�
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PLUMBER-GASFITTER NAME LICENSE VS-1 Ii SIGNATURE
MP P MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANYNAME .�wJCVN Gt4Y ADDRESS 7 0 bccen I. c lie Or,vc
CITY roreSTQACAle STATE" ZIP 0:4(914`i TEL, 02 367 L'n77
FAX CELL,cOP 3(77 leg 77 EMAIL P ►14 SP. Coin