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_� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ��
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'ititge CITY \\r,r �v -• .V� MA DATE to td IN IPERMIT# ertr-000 r
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A111 e�'1 JOBSITE ADDRESS VL3 Mr.% Q\Qtq e - IER'SNAME V-rn�1e
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OWNER ADDRESS o ," r'
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL®
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CLEARLY NEW:❑ RENOVATION:I. REPLACEMENT:fg PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 'II" (.. .. r II I .._ �1 ' .-.. .. 'iI 7—
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BOOSTER vSI.: 10111I '
CONVERSION BURNER �
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DRYER R I _ 0. pa _ .d..� ..
COOK STOVE , I es
DIRECT VENT HEATER I
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FIREPLACE —1 I : _ SRI ....401.091.111,' . 1
FRYOLATOR
FURNACE _ _ aTTHismsteFai
GENERATOR
GRILLEMI MMWr ilk
INFRARED HEATER lialr r __
LABORATORY COCKS 1
MAKEUP AIR UNIT an ia: F,•�R' .I, —1
OVEN _.r 1, ,. li II—
POOL HEATER .,I' ._. 1._._. .I . .. 11 _. _ _.
ROOM ISPACE HEATER r - ITO �'UNITHEATER . _ r c3flHhJ
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E E HDROOM HEATER ; A l IiiiiinE
1 I i l!nS�tielling
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Lnv (�//�$4)- -- I INSURANCE COVERAGE
I have a current Its ib lite insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES)]NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
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 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 applicatio ' in compliance wit = -e int provision
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4 V
PLUMBER-GASFITTER NAME eft_i\---( , S . jQct_t 1 I LICENSE#`(—let SIGNATURE
MP,(/] MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP pit LIC❑#
COMPANY NAME: e-Ci -i_. :k' ea,Q I.I DDRESS "Ti W C'LCI Iry S'( Q\2.Q-}-
, CITY 1 1\ LC- I STATE k'kt4ZIPQ), I,pSS TEL wtLDsz -(-P3(p-S
FAX CELL EMAIL
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