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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
c=_` r CITY: Lits I. y47R• "27 71(J ' MA. DATE: ) 22—/3 PERMIT# b/V—a yyi
JOBSITE ADDRESS: 2 pm/Cl4/4/ pigi-4 OWNERS NAME: Onw4,0 pcx_fw
G OWNER ADDRESS: c S•zJ in f TEL' FAX
TYPE OR OCCUPANCY TY • COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL al-------
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR—. I Bsmt 11 12 3 4 5 6 1 7 8 1 9 10 1 11 112 I 13 I 14 _
BOILER / I60I
BOOSTER I
1 CONVERSION BURNER I I I I _
COOK STOVE I I I I I I I _
DIRECT VENT HEATER I
DRYER I I I I
FIREPLACE I I I - I
FRYOLATOR I i n r r s : 1 i r r.7 r I
FURNACE I . _ �,__.__...._: I I
GENERATOR I I i
GRILLE I I 1 ,Ill '2 2013 I I
INFRARED HEATER I
LABORATORY COCK „- —'
MAKEUP AIR UNIT I Hy' rrt, 1/}3 / _
OVEN 7/0, G
POOL HEATER I •
ROOM/SPACE HEATER
ROOF TOP UNIT I
' TEST I
UNIT HEATER I I'
UNVENTED ROOM HEATER I
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 as please indicate the type of coverage b ecking 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 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 the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� .—
PLUMBERIGASFITTERNAME:40c14cG E�'f'RL}2ui LICENSE# /70� " SIGNA RE
COMPANY NAME:"`'7l C 1/4 c I 6--119 14 9 uT ADDRESS: z e r2 G r'pc"c 7 -4 u-(
CITY: tt/, 2,4a• STATE:rn19 • ZIP:00622 FAX
TEL CELL;SSO! — 9e2 0//f EMAIL:
MASTER 0 JOURNEYMAN INSTALLER 0 CORPORATION 0# PARTNERSHEP 0# LLC❑W 12°97
L12
ROUGH GAS INSPECTION NOTES
THIS PAGE FOR INSPECTORUSE ONLY FINAL INSPECTION NOTES
/rLSag Of a 7/a0/ Yes
This APPLICATION SERVES AS TilE PERMIT 0 0
FEE: $ PERMIT
!'LAN REVIEW NOTES
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