FEB 2016 P&G Permits Entered:6/20/2019 (002) MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
CrTY'. 11A I& DATE-0 PERMIT#
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OWNER'S NAME:Ejh
OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE: COMMERCIAL 177 IONAL E RESICENTLAL
PRINT
CLEARLY NEW:D RENOVATION: REPLACEMENT:�27T PLAN�.'ISUBKTTED: YES
T-
APPLIANCES- FLOOR-- 1 2 3 4 5 7 S. 1 12 13 1
BOILER tl
.BOOSTER
CONVERSION BURNER
COOK STOVE 4
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR -7-7
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AJR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER 7
UNVENTEC ROOM HEATER
,'vVATER HEATER
INSURANCE COVERAGE
I have a currerit jtzbi[' Insurance poky or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
If you have checked YES please indicate the type of coverage by checking the appropriate box below.
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LIABILITY INSURANCE POLICY OTHER.TYPE 1,11DE11.11,N!RY cuo F";
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 waves tils
CHECK ONE ONLY: OWNIER 4 AGENT E]
SIGNATURE OF OWNER OR AGENT
of the details and inform3ton I have submi"ed(or en-'red)regzrd,ingj this are true and d:,,=r8ta to the besl of my
Kriovdedge and that all plumbing worl<and insWadons performed under the permit issued for will'bei'ncompllaricle�14'tllletnent
�a"'ce 2
provision cf the Massachusetts-State Plumbing Code and Chapter 142 of the General Lars.
PLUMBER/GASFITTER NAME: Georqe 01Cb=e11 LICENSE a_jL9�4. ;7v /:GNATURE4'
CCIOPANYNA102- r)t(-hnnr5ji _Plrrmh�rq. -rnr-- ADDRESS: %F,,:a
CITY:. 1 1 STATE: Ty-TA ZIP: 0 1 FAX: _q
TEL: EMAIL: oco rnic,,11 11 .�):1cr@verizc2-i r-et
CELL:
WASTER JOURNEYMkI! LP INSTALLER CORPORATION P':,',TNERSHIP 7 L L C�_7