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—� MASSACHUSETTS UNIFORM APPLICATION FOR A PEFJNIT TO PERFORM
_GAS. C111rani. CASFITTINO W�RK
DATE
JOBSITEADDRESS �i ►��i1� ii O 7Cd PERMIT7l�1 -1D9
GOWNER ADDRESS: OWNER'S NAME 12,4
PRINTTYPE R OCCUPANCY TYPE COMMERCIAL �6ofo73-- FAX
CLEARLY Q EDUCATIONAL Q RESIDENTIAL Q�
NEW:0 RENOVATION:0 REPLACEMENT:0.7.--
FIXUTRES 1 pLOOR-• PLANS SUBMIT-0: YES 0 NO Q
BOILERm _
BOOSTER
11.1111111111. 1.1111111111111111111111111111111111111.1111111 13 14
COOKERS BURNER __ _
DIRECT VENT HEATER ==_1111____-______
DRYER _____ ______
la 11111.111111.11 111111111.NMI
FRYOLATOR ______ �_____
GENERATOR -=== _____
LABOR411111111111111111
TORYCOCK3 ====___a__=ororallinal
___�
ROOM/POOL HEATER 5�_�___�� =�_
ROOFTOP11111111111111111111111111111111111111111111111111
UNIT ACEHEATER -______ ____
ial
REESamantS
UNVE:NTED ROOM HEATER -_ _____
��_��_��_____�
iJl�l� 111.111111111111111111111111111111111111
�_____ s____
IN- iniriana_-____a ===___
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I have a turners t 'I' Insurance policy or Its substantial eIquivalent IANCE COVERAGE
e ___
If you have wed Y.E$please indicate the requirements of MGL Ch 142 YES^If p 0
type of coverage m9 the appropriate box below.
LIABELITY INSURANCE POUCY
OWNERS INSURANCE WAVER I am aware that the TKensee OTHER TYPE INDEMNITY 0 BOND 0
Massachusetts General Laws,and that my signature on this permit l�� this rcoverageequirement required by Chapter 142 of the
waives this requirement.
SIGNATURE OF OWNER OR AGENT
CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that all of the details and Information I have submitted(or entered a —
Knowledge
e and the that all plumbing yak and Installations performed uner the permit Issued for thisbore
Massachusetts State Plumbing Code and Chapter 142 of the General Lara. �W will be ,
PLUMBERJGAStITTER NAME -'q D TORE I%
COMPANY NAME; iw , LICENSE p�^j�-NRE
CITY: . ; _ ADDRESS: [1I(j�/
- a, STATE ��
TEL:c3E)M2ME:1 ZIP.®
CELL: FAX ��
EMAIL:
MASTER 0 JOURNEYMAN P2 LP INSTALLER 0 CORPORATION 4r- =1PARTNE32SHIP 0 p
ROUGH GAS INSPECTION NOT'S
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
f&t� 442 On L/L fr 0/g13 Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT I
PLAN REVIEW NOTES
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