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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING
eliieWn CITYROWN: • \Arm A rAA I STATE:MA APPLICATION DATE: b is/I I j
JOB ADDRESS: *r ! We ml ]A hi-_ _ _ ._ _I
GOCCUPANCY TYPE: COMMERCIAL❑ RESIDENTIAL PLANS SUBMITTED: YES El NO El
NEC ALTERATIOND REPLACEMENT REMOVALIDEMOLITION❑
r NATURAL&LIQUEFIED PETROLEUM GAS:PIPING-EQUIPMENT-APPLIANCES-SYSTEMS 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS
AIR ROTATION UNIT 1-1 FURNACE: ALL TYPES (-1 TEMP HEATING EQUIPMENT
BOILER:ALL TYPES —1 GAS PIPING ) THERMAL OXIDIZER
BOOSTER —1 GENERATOR(STATIONARY ENGINE) f TURBINE 4
BROILER — 1. ILLUMINATING APPLIANCE I I UNIT HEATER r
BURNER: ALL TYPES INCINERATOR f— WATER HEATER: ALL TYPES , 1
CO-GENERATION UNIT —1 INDUSTRIAL AIR HANDLER I I EQUIPMENT OVER 12,500MBH
COFFEE ROASTER — INFRARED HEATER M ro 7. It 2 1 1_1
COOK APPLIANCE HOUSEHOLD KILN 1 GLORY HOLE I CRUCIBLE J—I 1 q
COOK APPLIANCE COMMERCIAL —1 LABORATORY COCKS n
DECORATIVE APPLIANCE '—I MAKEUP AIR UNIT I-7 I I JUN 0 1 2011
DIRECT VENT APPLIANCE —I MECHANICAL EXHAUST EQUIPMENT I-1
DRYER: ALL TYPES OVEN: ALL TYPES (-7 GUILD:YO--
FIREPLACE:VENTED!UNVENTED I POOL HEATER I-1 ny i
FRYOLATOR I ROOF TOP UNIT
FUEL CELL I ROOM HEATER-VENTEDNENTLESS I I
PLUMBING/GAS FITTING FIRM INFORMATION CHECK ONE ONLY
(��---� fir- Corporation Business I I alb e-_�
NAME:I ' /` i r'2.-c-57;1:1-11-:=4.ADDRESS: t( l q,, c--1
— —,. Partnership Business i
CITY:.Ir(1- Yienla. 7 h (STATE:uZIP:1 ...I..%a;673-1. ❑
❑LLC Business ft
TEiuj O$ T7fi-4' 54 FAX: EMAIL: kmcp7r•'^'Lit. C&fl'i ❑DBA IUnincorporated
NAME OF LICENSED PLUMBER I GAS FITTER:
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES_ErNO❑
If you have checked lel please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of 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 ❑
Signature of Owner or Owner's Agent 1
OWNER'S NAME: rs , va n c evr RJ TEL:1—_ I FAXE 1
+
I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to
the best of my knowledge.I certify that all plumbing work and installations performed under the permit issued,will be in compliance with
all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws.
p(OFFFIICCzE USE ONLY) Type of License: �{f ./
Pergu{#;u 1` `4 r I ❑Plumber ❑Gasfitter LSC/�T��
Inspector L
QMaster ❑Journeyman Signature of Licensed Plumber I Gas Fitter
I ❑Undiluted LP Installer License Number: i 1 t2 U
Fee: J
❑Limited LP Installer
ROUGH GAS INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ '.PERMIT#
PLAN REVIEW NOTES
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