GP-89551 WNOfp
^ TOWN OF i EPA MET RE¢ iP , 9551
e4t e�a :tat s °:k .
t /� r� 400 ,
Name::j ll.( C Property Owner, og Z�jg Da it
Job ation: 0 /i 1-3-- 7) ,. `Flap: Lo /31'3h
c
0 eysriptj n General Ledger#'s Ref. # Amount
e •
'uildingBc Build Mise. �Y 01000-44105
b y
)rical-, '�� . ' oNcied 01000-44106
Plum as C. . 01000-44107 o cy IlL ?! $v� '9
Trench Sa 01000-44129,,��'41n
Other Department Revenue T0100b 10 wV'T s�
White-Collecta's Office Yellow Copy-Custom pP AIFet y-'9lafeb ChtS Received By no
THIS IS NOT A PERMITILICENSE FOR BUILDING, ELECTRICAL, PLUMBING OR GAS
•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
n=T=ia C'
CITYDG1ttMOv MA DATE A 3 97 aolg PERMIT#?g,?�
JOBSITE ADDRESS q0 1 Ir f 1 enf 'tv i OWNER'S NAME .3RIail\ t2 a ec-
GOWNER ADDRESS SO Mc (ICE-cS brio L TEL S28-(5 -5W9 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ,
PRINT C
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
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FI IRNACE
GENERATOR 1pcoo
G ILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER •
ROOFTOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER 6:ofWATER HEATER •
OTHER
•
, r
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECIlYES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY (51 OTHER TYPE INDEMNITY ❑ BOND1
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 on4is 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 and accura¢to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c pliance I h II P tinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
r �
PLUMBER-GASFITTER NAME 0PS OLCcs LICENSE#30r7- IGNAT E
MP❑ MGF❑ 11''JP❑ JGF❑ LPG' " CORPORATION ❑# PARTNER IP❑# LLC❑
COMPANY NAME W c � K Inc1Q GA-5 ADDRESS .".*114(Lr 4uC
CITY /////1.g,of/Ct STATE HA- ZIP --)2 .5-- ?—TEL 5 -a,-oil-'1l
FAX CELL 3-34( 130- itF3 S EMAIL UJcj KtwSoi,o CQf 5 4t-51 6p - 6)/(d/\ •
9tot ( 3
® 0
can
i-i
' N.1 0
z,
‘11 z
o I ,
wa
NA L 00
gob,
.
Ilk
a
4
cli 1 N
-..
..._
,.., th ..,...„_. ......._
hi..
20
4
rip• —Th
g w.7
O re
E-1 a
U an
P4 r I=
a 1- pra
(I) co ce 0-g
4
<
cri w >
a ;4 .
fz4 w g .
0
w ._,
;14 w
C.4
Q c;
< 0
< -
4 o
= li
E. o_
a_ •
CO to
r w
I- u_
CA
"\F) 0
Z . ,
‘‘,....
.........N.„...... S •
Et
CA•
A0
E
z
_.
L.,
= ,
(.)
0
:4
, sFie 4.: 0—.. .
„ .
t,,,...