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''' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
til—F• ' CITY: 22- A(thnt /7 Dr MA DATE: ' zg,— ( pERMgggf%12b/?-ei MP
G •IOBSITE AD �,�jj �tfkrNAME c,j (OM a %/IC,
OWNER ADDREss ` D' Vo� C).,y,' S' !S�K—�}J' (A��.
TYPE OR OCCUPANCY TYPE: COMMERCULL❑ EDUCATIONAL ■ RESIDENTWCCQ
PRINT
CLEARLY. NEW;0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCESI FLOOR-. Bind 1 2 3 4 6 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER r put
CONVERSION BURNER
COOK STOVEUM
DIRECT VENT HEATER I LMS Z
DRYER
7l !)
FIREPLACE
FRYOLATOR
FURNACE
El ,"
GENERATOR - )
,, GRILLE `
In INFRARED HEATER
W LABORATORY COCK -�
MAKEUP AIR UNIT m a
O OVEN
,Z) POOL HEATER
ROOM I SPACE HEATER •
`) ROOF TOP UNIT
Q TEST
Z UNIT HEATER —
ftl UNVENTED ROOM HEATER
WATER HEATER '
INSURANCE COVERAGE
I have a current liability Insurance poky or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO i
If you have checked f,please Indicate the type of coverage by checktg the approprlate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S IN ryTt7' WAIYEFC I aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachus d,!'r�. Laws,an• • .. my signature on this perm*application waW Gds requirement.
ids
'"��! CHECK ONE ONLY: OWNER W ^G ❑
SIGNATURE i e' ER ellin'�
hereby certify that all of the details and Information I have submkted(or entered)regarding fhb spplcatbn are. e end accurate to the best of my
Knowledge end that ell plumbing work and Installations performed under he print Issued forth application In corn•p. al Pertinent
provision of the Massachusetts State urrbing Code and 142 of the General Laws. A __
PWMBER/GASFii uH %Or.. tt1' e•--- LICENSE# . . /Se SIGNATURE /�
COMPANY NAME' fLS,YYt L(�[`!` ADDRESS 7-6 (ct�to Round" IR f j)
CITY: S. I (,v/Ytadik srATq��////��' e't/ WP.�Iil.Z6(�(1 /, "
TEL _ . ' .r= • EMAIL: Atom 6411 44 yro•
MASTER❑ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑t PARTNERSHIIP❑I LLC❑e
E 1,7n/C. ADD2ess:
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