HomeMy WebLinkAboutG-14-032 r'91'P / t`.V c'-1✓
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT'tO PERFORM GAS FITTING WORK
CITY: VA-rnro�.;(4 MA DATE: ?but3 PERMIT# 6fil 0
JOBSITE ADDRESS: , 571 k( h ro o R' OWNER'S NAME: (3 Fi F e
GOWNER ADDRESS: TEL FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT /
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 eft,- PLANS SUBMITTED: YES 0 NO❑
APPLIANCES1 FLOOR 1 Bsmt 1 1 1 2 3 4 5 6 1 19 1 10 1 11 1 12 I 13 1 14
BOILER
BOOSTER 1
CONVERSION BURNER 1 1 I
COOK STOVE
DIRECT VENT HEATER
DRYER 1
FIREPLACE I
FRYOLATOR I I 1
FURNACE I I
GENERATOR
GRILLE
INFRARED HEATER 1 I I 1
LABORATORY COCK 1 I !
MAKEUP AIR UNIT
OVEN
POOL HEATER 1
ROOM/SPACE HEATER 1
ROOF TOP UNIT I
Cr
TEUNIT HEATST 11 I_ I
ER I 1
!� >UNVENTED ROOM HEATER
5- WATER HEAT tit I
,
wee\ - 7III
s I I( INSURANCE COVERAGE
t (have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 12610 ❑
If you havgchecked YES,please indicatethe type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY L3 OTHER TYPE INDEMNITY 0 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 Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTERNAME: (Y;\1 F cit ev C) LICENSE,# /2 I & SI E
COMPANY NAME: AT PvM6 ' (?‘ I f ADDRESS: 3Y/ Pi a# sl^
clTY: C e A i e rv: \l O STATE: (ViA ZIP: 09 6 3 2 FAX
TEL: sag ya 9/Y 3 CELL' Sae 776- 78 3 O EMAIL' /3;1/ nit a. 6J Uer; Zon_,te
MASTER a JOURNEYMAN 0 LP INSTALLER 0 CORPORATiON 0 g PARTNERSHIP 0;± LLC 0
ROUGH GAS INSPE ' ON N• -E,' T1lIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTICS
nth/ 6 O Li2/1- 7a a Yes No
THIS APPLICATION SERVES AS TI IE PERMIT 0 0
FEE: $ PERMIT/ _
PLAN REVIEW NOTES
r
F _l.vmmurvrvCALI n yr mMbbML.nubc I I b
DIVISION OF PROFESSIONAL'UCENSURE=BOARD OF i
PLUMBERS AND GASFITTERS
LICENSED AS A MASTER PLUMBER ..t
4-11
ISSUES THE ABOVE LICENSE TO: 4,,tw - •
4 xLLIAH,54G ' FITZGERALD 2j
NOTTINGHAM DR
CEI":ERVILLE MA 02632-2136 =j
12912 05/01/14 171665
LICENSE NO. ?EXPARATION#LATE" SERIAL NO.'