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22B-015 (4) r�rc� - CITY V11Q1'41JC-? MMA DATE (r �' S' PERMIr# l5- ' 30 JOSSITE ADDRESS 5 -re Mel+g(aAl 5r OWNER'S NAME At>6�JP,/J S GOWNERADDRESS TEL FAX TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL[IEDUCATIONAL [IRESIDENTIALLA CLEARLY NEW:❑ RENOVATIONX REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS BSM 1 2 3 4 5 8 7 B 9 1 10 1 11 12 1 13 1 14 BOILER BOOSTER CONVERSION BURNER it V COOK STOVE DIRECT VENT HEATER 164 Fl E FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HE LABORATORYCOCKS MAKEUP AIR UNIT OVEN POOLHEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 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 CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECIGNG THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 4 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. CHECKONEONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify But all o1Ba details and information I have submitted w entered regarding this applica8on are true and aowrate W Ba eat of my knowledge and that all Plumbing work end inetalations perlormed under me permit issued for this application w11 be in compkia with I Penine provisiq of the MassachuseBs State Plumbing Cale/and Cw Chapter 142 of the General Las. PLUMBER-GASFITTER NAME a4c 1�rlgq LICENSE# 110y SIGNATURE MP MGF❑ J/P{P JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP[I n A LLC❑# .. C�MpANYNAMF ( ,INd.F I.,nf� 11,A&C l.1lY ''-�p�7R-�LsaTT STATE7l�NyJ ZIP OlVd � -_- TEL FAX FAX CE'LL Sao --73J- 7/ EMAIL 22 I� C! G`zlf 9,4