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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK n3
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MA DATE LA + kl`6 PERMIT# ikP6 /r GJ62/02
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r� JOBSITEADDRESS137 Crc � \ c r WNER'SNAMEI � ��, V ; 1
OWNER ADDRESS TEL (FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL •
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CLEARLY NEWS... RENOVATION:CI REPLACEMENT:❑ PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS-. B5M 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i_� a
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BOOSTER I I II • h —t
CONVERSION BURNER
COOK STOVE 'I . I
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DIRECT VENT HEATER •1 _ _
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DRYER ,
FIREPLACE r
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FRYOLATOR
FURNACE —'__ ..._ ....al.__.
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GENERATOR .. _ . _ .. ____ _ ..... —.._,
GRILLE I' r. P
INFRARED HEATER I .1 ... .. .. ... I1 .... .` L._ i ti m
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LABORATORY COCKS ^_._ d °_ _
MAKEUP AIR UNIT A_ _._I __;$
OVEN sl 1—!I Ili ii II •
POOL HEATER
ROOMISPACEHEATER
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ROOF TOP UNIT ( ... _'! ' + ....__
TEST '
UNIT HEATER
UNVENTED ROOM HEATER _
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WATER HEATER
OTHER Ii I I ul II
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u INSURANCE COVERAGE
., I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ElNO D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY 0 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
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CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are bye 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 complia ith all Pe t provi ' he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �__ p ���
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PLUMBER•GASFITTER NAME c c,r I 5 . IR; e d e 1 I LICENSE#-8.11-0 ...SE:-Te
.,,,E S ATURE
MP MGF❑ JP 1:] .JGF❑ LPGID CORPORATION Olt PARTNERSHIP # LLC 0/M
COMPANY NAME: (_earl R. IRiedell r Son ADDRESS 778 NIA in Street 1
CITY oshervt IIe. STATE 5tIP Oac955 TEL 50S- H S' - (o3Co5 .
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FAX CELL • EMAIL
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