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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: Yarn,0 urk Mk DATE 5/2.3/Z 3 pERmiT#gz 06- Za—goo 2.._
0 - JOBSITE ADDRESS: 3 3 ki ed.1)6 C RD• OWNERS NAME , IR,t I-el
G OWNER ADDRESS: 33 1-10.00 6( RO. TEL C 17 7/0 g?6 FAX: /
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 391/
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT
PLANS SUBMITTED: YES CI NO 0
tp APPLIANCES1 FLOOR-* Brimi 1 2 , 3 4 6 , 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
iliRECT VENT HEATERcYER
. .
f-.) FIREPIACE
t--1 FRYOLATOR '
FURNACE
GENERATOR ,
III
GRILLE -I , -1.c ! .: IV E..
vi INFRARED HEATER
L.:"., _.-7"-
d'I LABORATORY COCK
.
MAKEUP AIR UNIT k tkl 243 2(231
SI OVEN ____
POOL HEATER - — DEpin ma i
ltsi.p.io :
ROOM I SPACE HEATER I3U 11..Ei _______ -......___ __.
-NJ ROOF TOP UNIT
.ic• TEST
.Z UNIT HEATER
q UNVENTED ROOM HEATER
WATER HEATER
YVlks7 bo rt ter — 1 . ..
INSURANCE COVERAGE - -
I haves current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 15 NO 0
If you have checked yo,please indicate the type of coverage by checking the appropriate box below. .
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
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 0 AGENT 0
SIGNATURE OF OWNER ORAGENT
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 applicationy,.,.In.. .i= ,, all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.
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PLUMBERIGASFITTER NAME:RI..i".“cK 9e_yvk Dc,f-i UCENSE#31 i u SIG - ' RE ,j_
COMPANY NAME:teNRS el Pi t.)fYli,01,1+1-W-1-;f`JADDRESS: I-- z R-1- -t 130 filA,F11,1
CITY:CO 4-1-A.I 1— STATE:a_e_. ZIP: 0 g C 35 FAX
TEL:141 .31 a 7-1 1 lo CULT) 1 (3 1 a 719 6EMAIL: PLTD-e V14? S C• Cg S Q6rn el-.tid)rli
MASTER El JOURNEYMANy LP INSTALLER 0 CORPORATION 0# PARTNERSHIP El# u.0 0 it
E ir m/L ADDze ss: