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- SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CIT Q� MA. DATE: 6111 o PERMIT# 3
JO � ADDRESS: 2i`7 U ��./ U�j yr
OWNER'S NAME:
c,
R ADDRESS: TEL: FAX:
tER T 4
{ 2 PANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
A EARLY :❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES? OOR-+ Bsmt 1 2 3 4 5 6 7
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE c`�3
GENERATOR
GRILLE
INFRARED HEATER - �-
LABORATORY COCK 7 g
MAKEUP AIR UNIT �`c
._..
OVEN '
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
c
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY F6 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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT F-1
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 all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: �'�� L(CENSE#-&V' SIGN
COMPANY NAME:_�'/" ' Ci�+y �iC % ADDRESS: ` Lz M r kx'L L 02 .
CITY:aw�✓�t,/' STATE: ZIP: 0&2 d / FAX: 1661 �P61 �
TEL: 3°��/3'7_�5�,' CELL: �lJ ��/`I "S�ZS EMAIL: 4�{(° "2'C V fic'L ova
MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION, PARTNERSHIP❑# LLC❑#
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SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Cl MA DATE PERMIT#
J m E ADDRESS
ER ADDRESS TEL
T CUPANCY TYPE COMMERCIAL to EDUCATIONAL L1 RESIDENTIAL 0
PRINT
CLEARLY NEW:[1 RENOVATION:( REPLACEMENT:L] PLANS SUBMITTED: YES NOO
FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM " W
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM t
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ;
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR INTERIOR w
KITCHEN SINK c9
LAVATORY
ROOF DRAIN z
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
...............
INSURANCE COVERAGE: --
I have a current&kftinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 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 applicatioV waives this requirement. I
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 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 beat of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
P
PLUMBER'S NAME� LICENSE# SIGNATURE
MPN JP D C PORATIONEJ#'=PARTNERSHIP®# j LLC O#r-=
COMPANY NAME ADDRESS
CITY p; r` -�
._.......,_.._,�,a STATE ZI P I.-U I�C��,. � TEL 4 3- `���.�-,
FAX CELL I EMAIL
238 KING ST BP-2013-1101
GIs#: COMMONWEALTH OF MASSACHUSETTS
ME Block: 24D-070 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2013-1101
Project# JS-2013-001824
Est.Cost: $195000.00
Fee: $1170.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: AMARAL REVITE CORP 047740
Lot Size(sq. 1): 330184.80 Owner: TARLIN LLOYD D&JACOB RABINOV ARTHUR L SHERIN&SIDNEY R
RAB C/O STOP&SHOP SUPERMARK
Zoning:HB(100)/U (0)/ Applicant: AMARAL REVITE CORP
AT: 238 KING ST
Applicant Address: Phone: Insurance:
T J42 W ES i 91Q?k ST- (401) 454-6867 Workers Compensation
PROVIDENCER102904 ISSUED ON:513112013 0:00:00
TO PERFORM THE FOLLOWING WORK: DIVIDE FORMER VIDEO SPACE INTO TWO
SPACES
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Ins�ectPo�r,
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Underground:,' ) ' ,Service: Meter:
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Rough:')-��1->3 �t: Rough: House# Foundation:
J �> Driveway Final:
Final: Final: ��L t i n^ .
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