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MASSACHUSETTS UNIFORM APPLICATILoN FORA PERMIT TO PERFORM GAS FITTING WORK
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€NIK---7T CITY: YO,rni b L614.1 MA DATE 61 q PERMIT#BLDa-
JOBSITE ADDRESS 4 g Nck...v...hcm-tsh 1- R6 . OWNER'S NAME;,...lolvijci:itzpi.t.
GOWNER ADDRESS: TEL:5083101'i as'WAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL I: EDUCATIONAL CI RESIDENTIAL
PRINT
CUTARLY NEW:0 RENOVATION:0 REPLACEMENT:g.i7 PLANS SUBMITTED: YES ED NO
:APPLIANCES-1. FLOOR-4 Sant 1 2 3 4 ... 6. :6 J . 8 9 10 11 12 13 14
•BOILER ,
,
BOOSTER
1 , ,
CONVERSION BURNER
. _
COOK STOVE
DIRECT VENT HEATER , ..,.
DRYER • 0 E- CEIV7iD
FIREPLACE ...
FRYOLATOR
FURNACE - --
GENERATOR _
GRILLE
lji INFRARED HEATER BUILDING DEPARTMENT
'"V .i LABORATORY ootK
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. • MAKEUP-AIR UNIT . .
fi.., OVEN ,
' POOL HEATER
'V.
ROOM/SPACE HEATER _
--.,1 ROOF TOP UNIT
,t TEST ,
1.52: UNIT HEATER 0
143 UNVENTEO RAM HEATER - .
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WATER HEATER I
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. - -
INSURANCE COVERAGE
I haVe a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch,1,42 YES i NO EI
if you hare oriecked YES,please indicate thetype of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER;I ain aware that the licensee does not have the insurance coverage required by Chapter 142 of the
NlassaOhusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 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 a rate the bee ' !.y •';',. .
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be In pllan I, ..1 *ertirt o
provisiOn of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. 0 .--•?
PLUMBER/GASFITTER NAME: Ke.14-11-I-i3tre‘hairy) LICENSE# I 430 i SIGNA RE ,,,s
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COMPANY NAME:500S4A-1 JAW*. tkeect-1 n5(1 (08 in5 ADDRESS: 53 usvc tist f5 Pc41-\
CITY: 5,V4A-moi...4-1-41 • STATE: ntel_ ZIP: Oatzipq FAX:5CiTS-- '460—a(,0 I• .
TEL:5(R.,391?-6)9 O 1 CELL: . _ EMAIL; 6.d,w6r.e..5ne.,@ so uspn.,5110sre hs/04.1. 5 cod ii5.CAT)
MASTER RIOURNEYMAN E] LP INSTALLER El CORPORATION dif.3015Z C- PARTNERSHIP El# LLC 0#
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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s =1) r CITY Yo. ►n D u S 4 MA• DATE 518• PERMIT# Ri-D& ?3 — 9 Sv 5
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JOBSITEADDRES t g Wait NCLIt I'►l" Ra' OWNER'SNAMEdeAnciaC-`t'uk
OWNER ADDRESS TEL5 ! I ail FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[�
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[r PLANS SUBMITTED: YES❑ NO Er
FIXTURES-1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM •
DEDICATED GAS/OIL/SAND SYSTEM • _ _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM • •
DISHWASHER V _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN •
INTERCEPTOR(INTERIOR) •
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION • •
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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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 NO El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V OTHER TYPE OF INDEMNITY ❑ BOIND O.
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 an ccur e of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia with I frt pro ion of th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Ne`14+1-)Earn ha:m LICENSE# 1 lc p IGNATURE •
MP[✓]� JP 0 CORPORATION Rf#31.092C, PARTNERSHIP❑]# _`�` LLC❑#
COMPANY NAME�Sc^•US-1�,3hoee_, 41 t1J9 P( C001 i 19 ADDRESS 5-i• Lh �9 P 4-'
CITY Soul-k YeerIvIOL3' STATE-Kt ZIP Cake)cP TEL 508-3cl -•1090�
FAX 5O qt.° I CELL • EMAIL 4414 • - -- - _ - �- _- - - •