HomeMy WebLinkAboutBLDG-23-9334 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS Ho d ING WORK
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CITY l GL r vvt c ti%.4 11 MA DATE 4-5'�3 PERMIT#&De)- Z.3- (13 3 .
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JOBSITE ADDRESS .5 Gns-oj W j r4_a (AI OWNER'S NAME 1- Petal 60.1v,
Cr OWNER ADDRESS SI C. 61110 clfe. TEL 50$-73-/-5-311 FAX
OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL DE
PRINT
MA= NEW:52 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO p
APPLIANCES'b FLOORS-b 1SM 1 2 3 4 5 6 7 8 9 10 ! 11 i2 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER RIE c
FIREPLACE
FRYI OLATOR - JUN 2 2023
GENERATOR e/
GRILLE g!,�!LD1Nv uE=ARl Lh(f
INFRARED HEATER nY
LABORATORY.COCKS
MA4:EUP AIR UNIT
OVEN
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a carat liability jnsuraoce policy or its substantial equivalentwhich meets the requirements of IVIGL Ch.142 YES ® NO 0
I IF' U CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
I,?•AI31LfiY INSURANCE POLICY ® OTHER TYPE INDEMNITY ❑ BOND ❑
OtTn.1 W INSURANCE WAIVE i am aim fiat the licensee does out have the insurance coverage rewired by Chapter 142 or the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I here5rf cerliy that all of tite details and information k have submitted or entered regarding this appiication are true and accurate to the best of y knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in compliance ' all P ' on of the
14Aassactrttsetts State Plumbing Code and Chapter 942 of the general Laws. ,i
PLUMBER-GASFII►tk NAME ( 5 "e-rr IA)a et' UCENSE# SI RE
MP 0 MGF® JP ❑ JGF❑ LPGI❑ CORPORATION C]# PARTNERSHIP 0# LLC❑#
COMPANY NAME F C+cP ce-44ec►d• 14 f eu:-Lr ADDRESS G Al I(.t ti S i,1Jct 1_', r I
CITY ftaSk s°.>Q STATE MA ZIP ti-11 TEL 50%-'1r 1
FAX o,,AA CELL 50T-15C—eels EMAIL e ,•1A;ec) it -c 7 rs. cc en