G
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE PERMIT # _______________________
JOBSITE ADDRESS OWNER’S NAME
OWNER ADDRESS TEL FAX
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES
FLOORS
BSM
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
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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 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 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
_________________________________________
PLUMBER-GASFITTER NAME LICENSE # SIGNATURE
MP MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME: ADDRESS
CITY STATE ZIP TEL
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES
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THIS PAGE FOR INSPECTOR USE ONLY
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $________________ PERMIT # ___________________
PLAN REVIEW NOTES
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