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Home My WebLink AboutBLDG-23-008792 `' MASSACHUSETTS UNIFC7RM APPLICATION FOR A PERMIT TO PERFORM GAS FITTI�� 1'�G l+VORK Z CITY �' yocv--‘0k7H-f MA DATE �� —I" �''i _.�t PERMIT.*,[�""Z3'� 9d JOBSITE ADDRESS �5 `,1� 1 C1 AVE ' OWNER'S NAME NNvi 1 e_ G OWNER ADDRESS TEL TYPE OR FAX PRINT OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: Pr PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-F BSM 1 2 BOILER ' 4 5 6 7 ° 9 10 11 12 13 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR — FURNACE GENERATOR GRILLE ,---- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT • OVEN II POOL HEATER • I E- U D L_-_ ROOM I SPACE HEATER ROOF TOP UNIT TEST rMIY 1"/ 2023 - UNIT HEATER UNVENTED ROOM HEATER BJILDI G DE'ARTMFNIT WATER HEATER °y - -- OTHEf, L_ INSURANCE COVERAGE I have a current Iiabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES r NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ 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 AGENTCHECK ONE ONLY: OWNER El AGENT CI rb I hereby certify that all of the details and information I have submitted or entered regarding this application are true and . and that all plumbing work and installations performed under the permit issued for this application will be in complian 'best of io knowledge 1.74," Massachusetts State Plumbing Code and Chapter 142 the Gener 1 laws. 22 p rent provision of the PLUMBER-GASFITTER NAME Chi �tv LICENSE1 f* - SIGNATURE MP e-MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION(2c: 1 PARTNERSHIP 0# LLC COMPANY NAME 0�7-nJ G . 6t/L —t— j/47) � ��Sg ❑ �' ADD ESS (T CITY r Tb-1,2 c 7 -L STATE nrT - ZIP ® ,("I ti TEL � � _S �— FAX CELL SC5- Z2- 2P?j EMAIL CctC-e e),.,vr.pvN, anti hect