HomeMy WebLinkAboutG-16-2941 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
tare
' '': "4211la " CITY \larrn Of 11-11 Pork MA DATE /0-//a AV PERMIT#ISJDh//6'Q2.257q/
JOBSITE ADDRESS 14 4'] ROU to to A 'OWNER'S NAME Don a I d M'diets
GOWNER ADDRESS Sarno., ITEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL El
PRINT
CLEARLY NEW:RI RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO®
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 . 13 14
BOILER it 7- • - 1 r r
I
BOOSTER
CONVERSION BURNER I p I i i it n I
COOK STOVE
1111111 DIRECT VENT HEATER
III DRYER
FIREPLACE
FRYOLATOR 6
Rill,
FURNACE
i ,
GENERATOR I (p ie W
Nilo"
11/1
INFRARED HEATER 1
LABORATORY COCKS _', '
MAKEUP AIR UNIT d
OVEN
POOL HEATER
I
ROOM I SPACE HEATER I it
ROOF TOP UNIT
TEST
UNIT HEATER ;
UNVENTED ROOM HEATER I � i
WATER HEATER j, 1.
OTHER I I I
I
l 1 Ir -
__ 1 I' '',i I I.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES El NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE___,/ BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are Uu$S d accurate to the bes • m •wI-•ge
and that all plumbing work and installations performed under the permit issued for this application will be in comb i. ca with alley 'nen •rovi '•n of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L3 — �/� .. / `
PLUMBER-GASFITTER NAME V/ _ in 1..skA l/,1 /2i LICENSE# 6. ' SI -• URE
N
-
MP[✓j MGF Q JP 0 JGF 0 LPGI❑ CORPORATION d# a 15, _ PARTNERSHIP❑# LLC❑#
COMPANY NAME: 05/44,04-5 61010H4)/,F5 ,/NC, ADDRESS /(p./ ,goST "'7i .9e "
CITY foyg000 STATE /n•0- ZIP 02Q35 TEL 298'-033(-57/P I
FAX -..757.4 CELL EMAIL . 1pQ
471-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Rlpfr-- Lp/1i dX t fk //� � Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ _ PERMIT#
PLAN REVIEW NOTES
y
—1
•
i - .
i J.
rt,
. .-v*C•OMMONWE�ttH OF MRSSI� ,`�Iuser-m.-5.4i
•
r-, .Cs it • N • CISH OF MASSROHUSE7TS g • # DIVISION OF PROFESSIONAL LICENSURE
.�u L BOAR4oF PLNMSER&'04N1D &AS, J "
PLUMBER,5.1ANU GASFIITTERS'. (SSUr'r,� E 'FOLLOWPNG IGENk .*' ?
, . R ISSUES EHE FOLLOHINZ 11 • S =P' Li . y��A LLOW 1G PLUMB¢ •s
h .J ' .s
lit-alga AS STER PLH : _ = psi'
LEHANE
-1 .c-4(EV4.?} 14 LE(IANE
r' nyly f M LEHANE,: + �h r `
es-, . t-.,< • *.1,4(4.
4 t . 255 - I eH" "f ( 3req •• V .
I.
255 HIGH ST era 4i v •
x
4 ra''NTG "x 4A 02780 3;
r i a.tNrd l _ >ria 02780-3525 w ktmt. • _ r a I I.?
12868 ' .'d5/da'tS' '^^' 230111 - LICENSE NUMBER - EXPIRATION DATE. 'SERIALNUMBER
• • CONTROL it d,22 !050'• • ='.ONTROL# d2L 155_ - •
IMPORTANT - IMPORTANT
Ityour license Is lostdamaged or destroyed;Is inacaaate;or • f las fcense is lost,damaged or destro ed:is irk or
needs to be corrected,visit our web site at wass.gov/dplfor -acts to be corrected,visit our web site ayour Renewal
t massgovtdpl for
instructions to ensure the props waging of rola Ftmlexral Instructions to OSISUTO the paper mailing of pppl�tion and any other correspondence.Application and airy otherconesspaldmnce- -
This license is subject to Massachusetts General Laws and - This!cense Is subject to Massachusetts General Laws and
regulations.Your!cense Ts a privilege,and cannot be lent or
rs assigned
ignedanyr parson
is a entityunder
nprivilege.mrd cannotyofbe lent or assigned to any person or entity under penalty of law.Keep this
Berns eo to any person
son or e as required penalty law.Keep ibis license on yaw person or posted as required by law and/or
• rogue on your posted as by law and/or _ regulations .
-
jil(1//
j0/0
-2---W015d
po// so a.)