AUG 2016 P&G TG-16-344 APP r
L
MASSACI,IUSETT� UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY .. 4. , _,. .. _ MA DATE .� I�� u-6 s PERMIT � a ——
JOBSITEADDRESS , OWNER'S
R'S NAME :1_11�"-'
i
kff OWNER ADDRESS
�FAX ETYPE ._�
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL — 0 r
CLEARLY NEW: RENOVATION: REPLACEMENT:Q PLANS SUBMITTED: YES E] NC
APPLIANCES-1 FLOORS— 13SM 1 2 3 4 5 6 7 6 9 10 11 12T 13 14
BOILER _
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOI.ATOR W
FURN CE
GENERATOR
GRILLE _ r •_ __
INFRARED HEATER
LABORATORY COCKS (^
MAKEUP AIR UNIT
+OVEN
POOL HEATER —
ROOM 1 SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER - _ ..
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liabilily 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 J., O"rHER TYPE INDEMNITY BOND
OWNERS INSURANCE WAIVER:I am aware that the licensee doles 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.
SIGNATURE OF OWNER OR AGENT _ CHECK ONE ONLY: OWNER � AGENT
l 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws,
PLUMBER-GASFITTER NAME LBrian F.Murphy LICENSE#E325 w, SIG 1 '' —
MP F-1-1 MGF 0 JP 0 JGF LPGI O CORPORATION M# 993C PARTNERSHIPD# LLC 0##
COMPANY NAME: B.F.Murphy Plbg.&Htg.Inc. ADDRESS 72 Holt
en St, !
CITY Danvers STATE to]ZIP 21923 =TEL 9 -774-,3174
FAX 978-774-8709 _j CELL EMAIL briarlt�larawnsKB,corn