HomeMy WebLinkAboutG-14-313 11 �L_. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
J c%TS- CITY: Sil111 Y1tfr)1OOdj/ MA. DATE /04-13 PERMIT# bi/O3/3
JOSSITE ADDRESS: 99 Sail- 187COWNER'S NAME Miler- Rel as
G OWNER ADDRESS: TEL:.5os Q1/P4OC7FAX: `/
16;566; PR
TYPE OR�' OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL��
rIr
I t I CLEARLY NEW: RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR ( Bsrt 11 ( 2 3 4 5 6 1 7 1 8 9 ( 10 1 11 12 1 13 ( 14
BOILER
BOOSTER i I ( ( I •
CONVERSION BURNER ( ( I ( (
COOK STOVE ( I I ( (
DIRECT VENT HEATER ( I I ( f
DRYER ( I
FIREPLACE
FRYOLATOR ( ( ( (
FURNACE ( I ( •
G ( (
GENERATORif
GRILLE
INFRARED HEATER ( I
LABORATORY COCK ( ( I
MAKEUP AIR UNIT
OVEN { ,----.7 t .
POOL HEATER ( • _-- , r r '1- L+
ROOM/SPACE HEATER I ( ( � 1 •. �'. ( .
I ROOF TOP UNIT ( l I I. 6 'Jrl, 1 ; , ( _
TEST ,n� ^1 //
UNIT HEATER te;q1zr.S V' Z� 1 L I •
UNVENTED ROOM HEATER :�nnr_
WATERHEA1ER 1 L. ",.,,u
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ®-Nisi❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY..goe..--
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
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 Perlin nt
provision of the Massachusetts State PlumbingCodeandndChapter 142 of the General Laws. ,'/,� /rA�
PLUMBERIGASFIIILK NAME: Mill l enoir LICENSE# __ JG/�+f SIGNATUREN
COMPANY NAME: ADDRESS: /�( ?/K E
CITY: 1e21e100r1 OfCrSTATE ZIP:fGn.S3 FAX
TEL ddELL• EMAIL: -311.5,04.0/lief)&#id •00411
MASTER 0 JOURNEYMANLP INSTALLER 0 CORPORATION❑# PARTNERSHIP 0# LC 0#
OF y
2-
/
),)
ROUGII GAS TNSPECFION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
ge, &43 67-c GRg is lF Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ •
FEE: $ PERMITP
FLAN REVIEW NOTES
•
ti
4
•
COMMONWEALTH},OF.J�JSSACHU
-"DIVISION OF PROFESSIONAL LICENSURE-BOARD OF
PL.IaMBERS AND GASFITTERS '
p LICEktED JOURNEYMAN GASFITTER
ISSUES THE ABOVE LICENSE TO:
MARK T (WNARD E'
20 GRENI R BL.")
•� LONDONDERVI NH 03053-2364
. 5095 05/1.1/14 ' 150310 -_
LICENSE NO. EXPIRATION DATE SERIAL NO.