OCT 2016Gas permit TG-16-466 APP MASSACHUS TTS LINIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY C � .4, MA DATE V . ° ,. PERMIT#
_ ..7 5... .. OWNERS NAME r
JOBSITE ADDRESS �' .� `�� � v:c✓�'t�, ... ...,.
OWNER ADDRESS _ - TE4 .,. _ __..•�FAX i �
TYPE OR OCCUPANCY TYPE COMMERCIAL ,,� EDUCATIONAL �: RESIDENTIAL,
PRINT' rJ
CLEARLY
' NEW:i RENOVATION:r.,.- ,- REPLACEMENT:A, PLANS SUBMITTED: YES,w...j NO g„,!"
APPLIANCES I FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER ^. _.... ... ......... a. _...._
COOK STOVE
DIRECT VENT HEATER . . .. ... .......,.... ,-,. _. ,.
DRYER ........ .�,.... �� � n �..,.
FIREPLACE d
FURNACE ......_ .^�.�...rv._.I__.._._.I. .....-� d_.._...._ .._._.,_. A,... ..... . �,..._.. ..,_.._.�__.__... _....... _.. -.�,...__ . r... ...._..,M
GENERATOR ! ! l p
GRILLE ......... . ....�.. N:. _.-...� . .._Y _..,....._ . �... . ,.___. �V__..-...� .,.... .-. ..0. .. .... __. i4
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INFRARED NEATER _. ... .M N
LABORATORY COCKS P I M !
MAKEUP AIR UNIT I i,
OVEN
POOL HEATER
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ROOM/SPACE HEATER
ROOF TOP UNIT
....-, .
TEST
UNIT HEATER
UNVENTED ROOM HEATER _'� _,.,.., V, .__._..M.. ...,:.. . w .. . ...,.., . ..._...� ... -.. ,.. ..,. .....?
WATER HEATED
OTHER
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INSURANCE COVERAGE
I have a current Iiabili 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 OT'HER'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.
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 all plumbing work and installations performed under the permit issued for this application will be in compliance wtrtinent provision of the
r f the General Laws Massachusetts State Plumbing Coded Chapter� _.- , p 14 ,.._....., , . LICENSE# _- .PLUMBER GASFITTER NAME I �?' ,�`S�"i' SIGNATUR
MP; MGF� JP' JGF' LPGI CORPORATION # ""W - PARTNERSHIP; #'' ..
COMPANY NAME ADDRESS
CITY 5... .......... _. ._. . . _,_ T STATE zlPa ..., TELL / 6e,,3,Fbrag✓'
FAX' _.,...._- CELL' EMAIL
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