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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
vy- CITY: \,./�ri✓to��� MA. DATE ® // / PERMIT# c04 73 Ea
JOBSITE ADDRESS: i 0i,en 0 AIX, OWNER'S NAME ,3reaitchk inG /1
GOWNER ADDRESSS : J i'T .19,4ime/- s TEL: 1 s 1;7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIIALLEj
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMIt i tD: YES❑ NO 0
APPLIANCESI FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER --�-
DRYER E. ARP i
FIREPLACE --- _,-.
FRYOLATOR -
FURNACE
GENERATOR
, ' GRILLE -
flUILDiNC G,L-I'AMMElit i
INFRARED HEATERY
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER _ _
ROOM/SPACE HEATER
- ROOF TOP UNIT
TEST
UNIT HEATER
tii UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:lam 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
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that all of the details and information I have submitted(or entered)
Knowledge and that all plumbing work and installations performed under the permit issued for this application win be Irding this appication an3 true n comp withPertinentaccurate to the beat of
provision of the Massachusetts State PI tubing Code and Chapter 142 of the General Laws. / ;
PLUMBERIGASFITTER NAME: / �� ,��rCi�l v=it r LicENSE#_ ,'1 a/ � SI GNA RE
COMPANY NAME ,,_ ,eat, 60 ADDRESS:
A e ‘41.40 4 dek ii.ai
C1TY: iCl iP P'!l STATE v °l ZIP: 41 if fi FAX *II - .1 7,S" - -a--3-3- 14.1-1,�—
TEL: �1- a Y -D,1 CELL: Fr - C t 'EMAIL ® 44 b r
MASTER❑ JOURNEYMAN{] LP INS ��' ��1 aititil—
TALLER❑ CORPORATION❑# PARTNERSHIP❑
E irl�itr A2e�D� ss ----_ LLC❑#_