HomeMy WebLinkAboutBldg-20-000070 n '-:. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS I �.3 DRIB4 t.,lcal Erd.,e_. I OWNER'S NAME Its
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GOWNER ADDRESS i TELL JFAX --1
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL L RESIDENTIAL
CLEARLY
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RENOVATION: , REPLACEMENT:'Ll PLANS SUBMITTED: YES;, I NO
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOILER Im `__ + �E 3 .� J_ z 1� : ...
BOOSTER I L J i � S
CONVERSION BURNER I. :. 1 iir . .-... t 1 $#- '
COOK STOVE _ 1f _ [ � }' ;r �i tf ,
DIRECT VENT HEATER I.- — t� i 1, i. i . ,
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DRYER '
FIREPLACE l[ t 4,:: I w ,E ii AI 1
FRYOLATOR 1 J .._ 111 L Ir- 1i— --
FURNACE .� I $,
GENERATOR €-. „ i € iil
GRILLE `
INFRARED HEATER P , t! i !wi,
LABORATORY COCKS E_ gym_ � �� .. �__�! __ .�h- r �-- ,r ,�. [ i
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MAKEUP AIR UNIT 1. ,__. JL :-_ i J HI
OVEN . - l F-. TM... 3 `
POOL HEATER , - `. r. .— �� €,
ROOM I SPACE HEATER % �. ',.. . �,,., F F. . . 1 i� r r--Th .
ROOF TOP UNIT :; Fr ;,
TEST — ,�
UNIT HEATER GW. ' ,, a.ae _ IL __ I 1 4
UNVENTED ROOM HEATER i . ;' 1I €. qiJ -
WATER HEATER L 1 ` .._ r.
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OTHER _ i -- �L ! I I Li_ r, JE 1�
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L_ "NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I j OTHER TYPE INDEMNITY BOND I_JH
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusett General LawS,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER .... AGENT , _
S GNATU O�1 AGENT
I 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.
PLUMBER-GASFITTER NAME LDonld Eldredge LICENSE#113244 I SIGNATURE
MP MGF, „ JPJGFLPGI(, CORPORATION - # � 1 PARTNERSHIP 1„ ,. #1 1 LLC i #;
COMPANY NAME:Idwe plumbing I ADDRESS 190 north rd
CITY ;west harwich STATE` ma ZIP'02671 ITEL 1508-237 3544
FAX. g CELLI EMAIL Idwejrta comcast net
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