24A-194 (3) �* ��,^ _. O MA DATE' - FORM GAS FITTING WORK
_ ON FOR A PERMIT TO PER
MASSACHUSETTS UNIFORM APPLICATION
CITY �1VDn _' - �L�- PERMIT#�
JOBSITE ADDRESS — S�}. jOWNERS NAME '
G OWNERADDRESS ' t �ac:KbOv� - - ..
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.. . TELA-t3`F58-t{�."I. 1F
TYPE OR OCCUPANCY TYPE COMMERCIAL I_ EDUCATIONAL ; RESIDENTIALiy
PRBVT
CLEARLY NEW:I171 RENOVATION:'._! REPLACEMENT:V�' PLANSSUBMITTEDYES NO ✓
APPLIANCES I FLOORS- BSN 1 1 2 1 3 1 4 5 6 7 8 9 10 11 12 13 14
BOILER -
BOOSTER -- -- - — -- - -
CONVERSION BUR
NEP.
COOK STOVE - -- --
DIRECTVENTHEATER -- - -
'—
FIREPLACE !.- - --- - -- -
FRYOLATOR (-�T-(ACX LCA /- (meq.
FURNACE (/`y//
GENERATOR --_ -
GRILLE -- -
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT -- - --
OVEN
POOL HEATER -_-- -
ROOM I SPACE HEATER -
5 ROOF TOP UNIT --
TEST
UNIT HEATER kp KOV
UNVENTED ROOM HEATER �'L�y --
WATER HEATER 'C
OTHER . .-- - __ ___
INSURANCE COVERAGE
I have a current liabilityinsurance Policy or its substantial equivalent which meets the requirements of MGL Ch.142 YESjVj NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY f,,'. OTHER TYPE INDEMNITY BOND L.
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: OW! R . `.. AGENT
SIGNATURE OF OWNER OR AGENT
hereby artily that all of d installations
and information
rm I have under the per it entered regarding ing this application are We and Accu o the b bf Py on ledge
and Natallplumbing workani Codeatid performed fhistheperl Lissuetlfor this application will to in compliance wit ertinep �L:� he
Massachusetts State Plumbing Cale and Chapter 142 of the General Laws. '
PLUMBER-GASFITTER NAME Gary A Wilson Jr LICENSE#: 10839 _ NATURE-
MP' Ti MGF'J JP iJ JGF^ ,.. J _._ _. LLC # -_
LPGI CORPORATION # 2885C _ ' PARTNERSHIP i#�.. I
COMPANY NAME Wilson Services,Inc ADDRESS P.O.Box 1570
CIN Northampton, STATE'. MA ZIP 01061 TEL 4115843317
-- - J
FAX 4135843317 :CELL 'EMAILLgary@wllsonph cora (( ➢➢ I
1117
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CERTIFIED MAILF RECEIPT
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or on the trent tl space pemits.
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