HomeMy WebLinkAboutBLDG-23-8825 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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E D °7 rqf / h4A DATE 4 S �0)-3 PERMIT#BLOG-is- IS'Z1
' N O`JOBSITE DDRESS f! 1 55 Y Lr✓ OWNER'S NAME 14 it,' Grc ery
2023
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GVyIJ R DF'ESS TEL
QT pni DE RAeg 1✓�-N- FAX
p ry__ -_O(;quNIcYTYPE COMMERCIAL 0 EDUCATIOI4AL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:
PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS-. BEM 1 2 3 a 5 6
BOILER 7 5 9 to 11 12 1; 1^
BOOSTER _
CONVERSION BURNER, _
COOK STOVE
DIRECT VENT HEATER I
DRYER
REPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER _ I
LABORATORY COCKS -
MAKEUP AIR UNIT
OVEN
POOL HEATER -
ROOM I SPACE HEATER -
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTH - -
I I
INSURANCE COVERAGE �
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L'_J NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E 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 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 best of my knowledge
▪ and that all plumbing work and Installations performed under the permit issued for this application will be In con Me with all Perti provision of the
Massachusetts State Plumbing Code an Chapter/42 of the General Laws. ______-
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PLUMBER-GASH-ITERNAM �'"� ��
LICEPJSE# ��f33� SIGNATURE
MP 0 MGF❑ PI /J F LPG!0 CORPORATION❑# PARTNERSHIP❑* LLC❑it
COMPANY NAME S Pivvx io1 -f 11et,/,n� /J '</�
/� ADDRESS //sold- oi� I�i55 r�c( RdCITY STATE ZIP Ukb?g"--
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FAX CELL7-7 3573 S-'1?/ EMAIL rn✓ IIi(I/di s c (c load.co n'i
ROUGH_G_AS SPE�"TIC�I°(N{3T ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: $ PERMIT#
PLAN REVIEW NOTES
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