GP-69421 NO , ARTMOUTH - BUItDIN&DEPARTMENT RECEIPT 6 9 21
PHONE: 508.910.1820 '�AX 5 8.9110.1838 ( i \
Name:411K 7.7? \ ..Property Owner• >} j Date:
,1 ki
Job Location: / L �` Map: C Lot: /J�
Description General Ledger#'s 4efM ' Amount
Building& Building Misc. 01000-44105
I APR - 5 2013
Electrical 01000-44106 kk. �.) 5 1
Plumbing & Gas 01000-44107 Axial. :'% (/7 L/
Trench Safety 01000-44129
Other Department Revenue 01000-42420
white-Collector's Office Yellow Copy-Customer's Receipt Pink Copy-Building Department Received By
THIS IS NOTA PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
jar-}-moo MA DATE, _.._ .
CITY ..__ .. y;-S o�Oj� ';PERMIT#
JOBSITE ADDRESS Q LA n e OWNER'S NAME l W0b_er- &. eN Co J r^�"',f
G
OWNER ADDRESS Some TEL !FAX'
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL l." !� "�`G
PRINT ,-, RESIDENTIAL �"
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 -
COOK STOVE le ii !
ll
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR G .
'
FURNACE
GENERATOR ,'
GRILLE
INFRARED HEATER l' D
LABORATORY COCKS �
MAKEUP AIR UNIT ` —=
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST ,�
UNIT HE
ATER EATER I
_ _
I
UNVENTED ROOM HEATER
WATER HEATER I
IIOTHER
, - .
i I ,
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 17 t NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND
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.
-.r
CHECK ONE ONLY: OWNER AGENT I„1
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 compliancucte with all Pertinent provision of the
Massachusetts Slate Plumbing Code and ChapterFL
'142 of the General Laws. �—
PLUMBER-GASFITTER NAME
Edward ((, CGw.c.,rc� • rrr 1 LICENSE# Ip_CI I SIGNATURE
MP MGF , JP „ JGF LPGI:V CORPORATION r `#; PARTNERSHIP n#7 LLC i #
COMPANY NAME $t . DDRESS i!
Cab 2f' `- Av.2v- 1Q.5 QLn Ce CG,- _,L-�'Sfz +c... �t,y vim , 7 -
CITY , Q or STATE,
>w, ZIP` b22` 4 JTELpy� (p .(¢
��Si A.
FAX: CEL
4o0 /S_egu EMAIL; — —
z
0
n
x
0
v
N
z
N
ro
n
o
0
z
z
0
y
cn
m -I
m x
N
4 V
x
n N
y Z
m
�j N
m n z
M 3 -Ni M
q m n
O m G
b ❑m o
z
❑ r
o K
V
CrD r'
z
_ 1=1 t \ z
r— it
r"t-t \, �y
-� NA oz
r-n
C= \ o r
1