G-19-1776 i6/z f e v�v1
SZ), MASSACHUSETTS UNIFORM APPIJCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CfTYMA DATE (g PERMIT#/ 7 Jr c'J/'7(p
JOBSITEADDRESS, B gjNC{e kum Lp 1OWNER'S NAPE f g CUAW.W FERR t 5
G OWNER ADDRESS ( 1TEITYFAX
PRLNTPEOR
OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:D ' RENOVATION:0 REPLACEMENT: • PLANS SUBMITTED: YES 0 NOD
APPLIANCES 1 FLOORS-• BSM 1 2 3 4 5) 6 7 8 9 10 11 12 13 14
BOILER
h
BOOSTER
CONVERSION BURNERCOOK STOVE diiP �•. m y . W:ia A 4 bA J'.i=t _ 'i 2 'A•':.
DIRECT VENT HEATER
DRYER - - .
FIREPLACE
FRYOLATOR •
FURNACE
GENERATOR
4� � ..
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _,', z •.s _ ,
OVEN -.
POOL HEATER
ROOM/SPACEHEATER
ROOF TOP UNIT
TEST o s., 2 . _ ._ -r F • _r
•fis_ .--err_- za . - --.e'_:- TECAt:- ,. - Jaz:: -' Y UNITELATE R !iPm! J1i e `v
INVENTED ROOM HEATER
WATER HEATER , _
OTHER I
DIN e
INSURANCE COVERAGE
I have a current Jlebility Insurance policy or Its substantial equivalent which meets the requirements of MOL Ch.142 YES LAO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY c( OTHER TYPE INDEMNITY I BOND 0
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 I,j 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 aoaaete to the best of my knowledge
and that all plumbing work and 4s6aiatlons performed under the pane Issued b this application will be h canpUance with all Pertinent provision of the
Massachusetts State Pluming Code and Chapter 142 of the General Law i S 1'^'r+
PLUMBER-GASFITTER NAME',Waiter Nye UCENSE#•32083 RE
MP U MGF D JPO .IGF 0 LPG[1 CORPORATION 0#jJ PARTNERSHIP M#1,_ _ j LLC #�
COMPANY NAMEyNye Plumbing and Heating !ADDRESS 349 Great Western Road
CITY 'Harwich STATE I MA 121P 02645 (TEL 508-2463349
CELL -
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