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Home My WebLink AboutBLDG-23-9695 MA+SACHUSETTS UNIFORM APPLICATION FOR A PERMET TO PERFORM GAS FITTING WORK %, Cm( lij�es1 �G(!' MA DATE �/ ✓ Z5 '46 s; (/ PEFtIvIIT J 3 `i�`i' JOBSITE ADDRESS ,i S1:I40/cA kb OWNER'S NAME R08 PC L,! kJ OWNER ADDRESS -S—A Ii C. TEL S� 65'/ FAX FAX• TYPE OROCCUPANCY TYPE COMMERCIAL'`�C EDUCATIONAL PRINT El RESIDENTIAL❑ CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ GTE Lei PLANS SUBMITTED: YES ❑ NO❑ APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 111 12 '13 14 BOILER _ BOOSTER CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLEI INFRARED HEATER LABORATORY COCKS --, , MAKEUP AIR UNIT OVEN r' E 3 POOL HEATER ROOM/SPACE HEATER 1' ROOF TOP UNIT — I N�V 2 C 2023 TEST ---1B ` UNIT HEATER ,h _ _, R tMcw . UNVENTED ROOM HEATER WATER HEATER OTHER 45 Lf,A Q - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIGL.Ch.142 YES ❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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. CHECK ONE ONLY: OWNER I 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 tru nd 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 co ha ce ' P Went provision of the ''`` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. CL� ' , �Z PLUMBER-GASFITTER NAME LICENSE `/:S l js` SIGNATURE MP ❑ MGF❑ ��JP [� JGF❑ LPGI ❑ CORPORATION, ❑ F PARTNERSHIP❑�t LLC❑ COMPANY NAME Dte;yl 0 l j top(, f t I '4'41w' ADDRESS 4 Z el g'll CITY 4v1G'll/1614 STATE Ril ZIP CLS S TEL SZ "/ C°Y` FAX CELL 5-- 4314r-7 EMAIL `! t j41. 9 /QGi., s Cad 1 — I I) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ^--fir--`J"'�' it L��L��'N CIT`( ��! J `.� MA DATE ./ �� PERMIT t. �jL(�j 0- 2, �- JOBSITE,ADDRESS /�7 S./.4n✓i//S KC OWNER'S NAME 0 e QT 0€-e.-I 0 OWNER ADDRESS J i TEL co� �4 $ F ?ATYPE OR PRINT OCCUPANCY TYPE COMMERCIALX EDUCATIONAL CLEARLY ❑ RESIDENTIAL 0 NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ 6745 le4k PLANS SUBMITTED: YES ❑ NO❑ APPLIANCES t FLOORS—F 6SItn 1 BOILER 5 6 o 9 BOOSTER 11ale ® 13 1 _____ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER all= FIREPLACE — FURNACEall - GENERATORMIMI iii- GRILLE • INFRARED HEATER LABORATORY COCKS _ MAKEUP AIR UNIT OVEN _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT .1.111111 �` — _ TEST i� � 7-1.-- UNIT HEATER ® .._ . UNVENTED ROOM HEATER ®® _.._. WATER HEATER ,i i ,,'47,41 111111=1--------- I have a current Iiaf,iBi insa�rance policy or its substantial equivalent NSURANC hi E OVERAGE -_ the requirements of I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE sAPPR APPROPRIATE BOX B E BLGL, Ch,� � YES NO ❑ LIABILITY INSURANCE POLICY [� MOW OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Ater 1�8.,Chapter 7 of the Massachusetts General Laws,and that my signa¢ttlre on this permit application waives this requirement. �e .� SIGNATURE OF OWNER OR AGENT CHECK► NE ONLY: OWNER "�;: I hereby certify that all of the details and information I have submitted or entered regarding this application L AGENT and that all plumbing work and installations performed under the permit issued for this application will be in com li • f�4assachusctts State PlumbingPP n are true a ccurate t e s ` Code and Chapter 142 of the G t of my knowledge general Laws. p ce ith rti t provision of the PLUMBER-GASFITTER NAME v �S7�S- I�P ❑ MGF 0 JP LICENSE#/ 5/ ? SIGNATURE JGF❑ LPGI ❑ CORPORATION ❑ I COMPANY NAME / �S. Ejtse Al PARTNERSHIP❑�� CITY�AU/10O l<li ADDRESS STATE_I _ ZIP 02 C.K.3 TEL F v S'✓ SY FAy` CELL c- �/ ` 967 f/ �/EMAIL !7 c�I ,C,�Qi�L,� 4 ,4 C L C, Cv lo(DD (