HomeMy WebLinkAboutBLDG-23-9348 T -1. .-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM
' ,y GAS FITTING WORK
�`` 1(711 MA DATE 2' 3 Z 3-F3Y9
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JOBSITE ADDRESS 7 3 ! d
G OWNER'S NAME C►l0e
OWNER ADDRESS
TYPE ORTEL FAX
PRINT OCCUPANCY TYPE COMMERCIALS EDUCATIONAL
CLEARLY El RESIDENTIAL❑
NEW:❑ RENOVATION:0 REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--► WEIBOILER 3 4 5 F ' ° 9 10 11
Es BOOSTER -=-�� �- 1s 14
BOOSTER CONVERSION BURNER, -= -
COOK STOVE �� -�
DIRECT VENT HEATER _-
DRYER al
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IIIIN
FIREPLACE
FRYOLATOREMIIIIIII= -GENERATOR -�
GRILLE mimminnum
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INFRARED RY COCKin=1111111MS
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LABORATORY COCKS
OVENK4AKE
AIR UNIT =--
OVEN --_
POOL HEATER t
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ROOM I SPACE HEATER
ROOF TOP UNIT S =NM
UNIT HEATER ®_ . 111.111111 _�
INVENTED ROOM HEATER -� =�
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WATER HEATER n
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OTHER �� = MIN
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I have a current liabili insurance policy or its substantial equiva111111
allent which meetsee the requirements of MGL.Ch.142 YES
el I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOWNO ❑
LIABILITY INSURANCE POLICY gr OTHER TYPE INDEMNITY ❑ BOND
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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.
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`� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT 0
"l:. 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 myknowledge
`` and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. owledge
Li provision of the
PLUMBER-GASFITTER NAME
LICENSE# SIGNATURE
MP❑ MGF❑ JP El JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑#
COMPANY NAME We.1 V Lim LLC❑#
ADDRESS q!-b✓ 4 j l/✓W U
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CITY f`GV �► y�y G A'1Gc�-�A STATE ZIP Oa- C TEL
_5� 3?S36
FAX CELL /�
EMAIL We Qiot C?V 414 h Jr) '1
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r? OMMON EALTH OF -- 6.
DIVISION OF OCCUPATIONALQ LICENSURE
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PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN P1 UMBER
JOSHUA A CARLINC) a....
PO BOX 149
CENTEFL .E,MA z• 02632-01+4J i •
U
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30034 001/2024 296918
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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