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31A-001 (4) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY !'Northampton --1MA DATE 7/8/19 PERMIT# JOBSITE ADDRESS!336 Elm St. Church OWNER'S NAME 'Blessed Sacrament Church OWNER ADDRESS 336 Elm St. TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: _ PLANS SUBMITTED: YES NO APPLIANCES Z 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 FURNACE GENERATOR GRILLE INFRARED HEATER 11 LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT Ntfrrtun, +q,, t SGUOQ TEST t UNIT HEATER P L P NIBING GA INS EC OR UNVENTED ROOM HEATER (v RTH MID ON WATER HEATER_ AP -HO FID NO AP R E OTHER i 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 CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v 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. 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 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 compliance with a erti nt pr vision o Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ Z � PLUMBER-GASFITTER NAME'LRichard Paige LICENSE# 11257 SIGNATURE MP' MGF® JPq ? JGF LPGI CORPORATION #,2365 PARTNERSHIP'J#L__��LLC g# COMPANY NAME:;F. Paige Plbg. & Htg. Sery Inc. J ADDRESS,19 Knollwood Dr. CITY IEast Longmeadow STATE MA ZIP 01028 'TEL�— . FAXI CELL 413-218-2002 EMAIL'paigeplbg@gmail.com 3� �4- 0oI 0jVttc a�qa-1 31W00 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYNorthampton MA DATE 7/8/19 PERMIT# '�V109 ti JOBSITEADDRESS,336 Elm St. Church OWNER'S NAME Blessed Sacrament Church G _. _____---- OWNER ADDRESS 336 Elm St. TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT 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 FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS j MAKEUP AIR UNIT OVEN I L11 Jul. POOL HEATER ROOM/SPACE HEATER El ROOF TOP UNIT Niwt'i,. .,,', - TEST is wi, ?Ail i UNIT HEATER t41B WG GA IINS IEC OR UNVENTED ROOM HEATER N 0 RTHI!,'IP ON WATER HEATERAP RO ED NOT APPRO E 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 CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v 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. C _ SIGNATURE OF OWNER OR AGENT HECK ONE ONLY: OWNER 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 compliance with a ertint pr vision o Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME jRichard Paige LICENSE# 11257 SIGNATURE JP JGF LPGI CORPORATION t #2365 PARTNERSHIP ,,J# LLC #' .. t L L�� COMPANY NAME: F. Paige Plbg. & Htg. Sery Inc. )ADDRESS 19 Knollwood Dr CITY East Longmeadow STATE MA ZIP 01028 TEL' FAX _ CELL 413-218-2002 EMAIL paigeplbg@gmail.com r' s;1�J�� �� ��� �/3�/�� �es� � _ _ fra [ t-'vi �'� `� � �%� �i,� _. t..: i _. I ..