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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TOPERFORM GAS FITTING WORK
-:-23it= CITY: vv‘O 0 1k� J CMA. DATE: 4-I I kc I i J A(-LI
PERMIT ( MY
JOBSITEADDRESS: 6S Cts\ippin 3weCY'tC1OWNERSJahn nhn L
G OWNER ADDRESS:Sr rA TEL 5C' fl b0, 2040AX:
r TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL jJ
r� PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR-» Bsmt 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 COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT •
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER •
•
•INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ® NO 0
If you have checked YES•please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 I be In compliance with all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter142of the General Laws.
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PLUMBERIGASFITTERNAME: Geo e Bk) L1,�VSY-LICENSE# -11a(o `af gep E
COMPANY NAME:MG1Ja0hekI Mgr N6itia(ADDRESS: -1 I SCkoo` StivPe
CITY:
\\JesV b-(211VIASSTATE: AM ZIP: 02-(0-10 FAX:.55' 08 3C 4 . 5050
TELL. 08.3cf 4 000 j CELL: EMAIL: it. - 1 r f
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MASTER 0 JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0#35350, PARTNERSHIP 0(J O U LLC❑# 111
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