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Name: —, :‘,,- , -------- Property Owner: ', —.;• ,`, - ' ',.- Date:(
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Job Location: 'Ll ).--- _N- 1 :7 r ,...) -, ! i (--k- Map: ti I Lot: ,,-,„>e _.,(---
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Description GenGenaFtedr#'s Ref. # Amount
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Building& Building Misc.
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Electrical 1 01000-44106
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Plumbing 8/Gas ) 000-44107 (.."-(,,,..L.,-t,6'it /,„•fti •---
Trench Sakty„,./ \ f31000944
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Other Department Department Revenue 0 i:. '-A 20
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White-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By ,-._,k.' i
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�� CITY -, MA DATE I��// /7—/ ' I PERMIT# 75 '�
JOBSITE ADDRESS ( 1 p � OWNER'S NAME 'CAM 1 tip � u_...
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OWNER ADDRESS ?3c� 6,.r1,A0eA e ? ....,.. TELLb - T ( j7 iFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL€,. RESIDENTIAL j
PRINT ""
CLEARLY NEW RENOVATION:;, REPLACEMENT:Li PLANS SUBMITTED: YES, ; NO;
APPLIANCES 7. FLOORS—* .-B8191 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER t/
BOOSTER ___
CONVERSION BURNER L. �;,, , ,-,,,. ,; , ', Po IL ,t,.., .., „r.;;,
COOK STOVE � 'Y ��
DIRECT VENT HEATER '
DRYER
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FIREPLACE j, r, r ;�
FRYOLATOR
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FURNACE E
GENERATOR
GRILLE �^ r
INFRARED HEATER 6 i !r L I
LABORATORY COCKS i ..,... ., ,,' ..z .,M „�,;.;::. * .v :,'..,. . ., 'I
MAKEUP AIR UNIT ` r
OVEN i��� 0r �s s lii_ ..
POOL HEATER 9 t., ! a r 1I
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST ✓ “nCleYcrvu✓1cJ I ..._
UNIT HEATER J �_
UNVENTED ROOM HEATER "�'� , "�"`
WATER HEATER0 r
OTHER 1 i--•- „,
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES (,,,v 'NO ' !
I II-YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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.
CHECK ONE ONLY: OWNER ET, 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 complia c ywithhl
all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `G( 1�
PLUMBER-GASFITTER NAME, e ..._ LICENSE# ? 7Z fJ NATURE
MP; MGF T,73 JP JGF-, LPG •• CORPORATION i #: PARTNERSHIP ,„# LLC =#I
COMPANY NAME-JaySan Gas Service,Inc ADDRESS P 0.Box 746
CITY East Freetown STATE MA ZIP 02717 1TEL 508-763 2729
FAX 508 763 5400 CELL°508 942-7013 <EMAILInfo@jaysan9as.com I
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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THIS APPLICATION SERVES AS THE PERMIT
FEE: $ f PERMIT# 75 757
if8g\- )-) PLAN REVIEW NOTES
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