HomeMy WebLinkAboutBLDG-23-1205 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Werm 1'
ACV V CITY la11'1'1Qu PVI MA DATE 5-b-25 PERMIT# QL 1)(0" 2-3 I Z 6S
JOBSITE ADDRESS 23 Glen c,JQod fib- OWNER'S NAME AAA KK boC
GOWNER ADDRESS 23 lxlenccioAvd l,t/6L411' 4k TEL 6VT-5t2- base FAX
n1b13
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL Er-
PRINT
CLEARLY NEW: Er" RENOVATION: El REPLACEMENT:El PLANS SUBMITTED: YES El NO❑
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE I
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER E V E. 1�l�
ROOF TOP UNIT ^--- -
TEST
UNIT HEATER L MAY 1 1 2023
UNVENTED ROOM HEATER
WATER HEATER { BUILD I_ . _
OTHER _� ' NT
---
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES iyf NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [f OTHER TYPE INDEMNITY El BOND El
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 El 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 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. /
��l f�y/,ri.G7
PLUMBER-GASFITTER NAME Feimand° coeih& LICENSE# L 6 7 SIGNATURE
MP[r MGF❑ JP❑ JGF El LPG' El CORPORATION [r# L-{-{oO PARTNERSHIP❑# Lc El#
COMPANY NAME ALL CAPE and gum bind I y+G ADDRESS (h tOt‘d ukh_i`4X� %
CITY vJe3- Vol rrlOtPilik STATE MA ZIP 0Zb?3 TEL 568 -3bN -542-5
FAX CELL EMAIL niiCoiftf,hlrC.card 4RaMbinc. 671
Ctcyy,