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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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.` CITY 5-bu:7L % t /__ ___ MA DATE 7/ Zc)// 5— PERMIT# 41--DPP--A 006
JOBSITE ADDRESS Z S..._. ?AA,' ,G, kd.-... , OWNER'S NAME G
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL v' a- 00
PRINT
CLEARLY NEW: , RENOVATION: . . REPLACEMENT: ✓ PLANS SUBMITTED: YES _ NO'
APPLIANCES 1 FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
_
CONVERSION BURNER
s
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE ,
FRYOLATOR
FURNACE _~_: _._,._ _3 _.. _. ___.r.
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER _.. _. .. __.. .__ ; _...__ _.. _...___.
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current Jiability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 141 I�Q ,
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL, u�0:,,,4,�.3 44,0dU
LIABILITY INSURANCE POLICY v OTHER TYPE INDEMNITY -__; ' '\.BOND I y..'
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 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 complian Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME .1.44/ / rsi LICENSE# /j177 SIGNATURE
MP 1MGF JP ..-_ JGF LPGI CORPORATION ✓ PARTNERSHIP :# LLC #
COMPANY NAME:CA-pc,God1%"i0-#r c rkC ADDRESS y.A„al JC.._._YZi
CITY 5 DeAhvif STATE
_... /44- -ZIP Q 2ii 0 _ TEL ,.+$-0_, -LZ�..�-? Z Zoe
FAX
FAX ._._- .._ . ._ CELL .. EMAIL
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