24A-091 18 DICKINSON ST MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY i�\ lX _rYI��LYI MA DATE PERMIT
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JOBSITE ADDRESS A �c�C��S�, F OWNER'S NAME �:rn {'Gll 71,10
GOWNER ADDRESS TEL NI j -M cl FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALO
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:Iq PLANS SUBMITTED: YES❑ NO❑
APPLIANCES Z FLOORS— ssM 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
FRYCLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
i
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER MP N
WATER HEATER AP RO ED NOT APDRO:: ED
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-k OTHER TYPE INDEMNITY ❑ BOND ❑
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.
Ate,c'�- 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 accurate to the best of my knowledge
and that au plumbing work and installations performed under the permit issued for this application will be in CO `anceall P ine visi `of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASFITTER NAME ,��a QU•J1 k LICENSE# SI NATURE
MPt, MGF❑ JP[I JGF❑ LPGI❑ 1 CORPORATION❑# PARTNERSHIP # LLC❑#
COMPANY
NAME e-\ ADDRESS :] 1 1, �n1
CITY_ ( C -�`LK�1Y7 '�1 STATE ZIP Oy%�� TEL
FAX CELL EMAIL
ROUGH GAS INSPECT ION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Ys N
THIS APPLICATION SERVE-SAS THE PERMIT ❑ ❑
FEE: PERMIT#
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PAN RE,ylEW NOTE
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