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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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��_,� CIN; /!,{/`rYIUlI G1 MA. DATE: S-`�^/.� PERMIT^R �/ �9S
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JOBSITE ADDRESS: IV e eri t r cif, OWNER'S NAME 6//4402/1 '4u4NP//J
G OWNER ADDRESS: • (O$ (/2'? Gti( FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:IX REPLACEMENT:0 (/0-/a)
j0/a) PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR I Bsmt 1 1 2 1 3 4 5 6 1 7 1 8 1 9 10 1 11 12 1 13 I 14
BOILER 1 1 1 1 1
BOOSTER 1
CONVERSION BURNER I 1 1
COOK STOVE
/ 1
DIRECT VENT HEATER I I 1
DRYER I I
FIREPLACEI rt I 1
FRYOLATOR I 1 _
FURNACE 1 1
GENERATOR / I
GRILLE _
INFRARED HEATER 1
LABORATORY COCK - 1
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER _
ROOF TOP UNIT I
TEST I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEAIttt
INSURANCE COVERAGE
I have a current lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES IA NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY [j 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 0 AGENT 0
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 thv.est of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will� p6�a •I all Pertinent
provision of The Massachusetts State``Plumbing Code and Chapter 142 of the General Laws. l
PLUMBER/GASFITTER NAME: (rr: L7Ttrcti°6V'. / LICENSE# — /" •TURE A
COMPANY NAM/E: imic ( nrr4vt /ie' Cera<%.04 DDRESS: BSc p/ - �7T �i//hJ /a
CITY': � M., STATE: M ZIP: Dan Stre FAX:
TEL /7/-C2,/)-Cie .rGELL:_ SCIS - EMAIL: tyfordellet a p/lee4hre/]j
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MASTER JOURNEYMAN❑ LP INSTAI I g CA1,4).441g4 1 ✓ PARTNERSHIP❑# LLC❑#_/
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TROUGH GAS INSPECTION NOTES } TIlES PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
gall- 643 cit 4421- 017/`7 Yes No r/ r-✓� ovv /Ori5
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ' yl
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FEE: $ PERMIT//
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PLAN REVIEW NOTES
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