HomeMy WebLinkAboutG-13-277 �__ 6i�-a7)
Z, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'' a CITY I Yamrouth I. MA. DATE /8 I!a- I PERMIT ft vM"121
JOBSITE ADDRESS L. a Sin I Law tj(tb(,c r A I OWNER'S NAME I 14I[Q n 0-641 -
G I
OWNER � Sn�.2 � TEL: 0$399 8437 I FAX:I • i
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑' RESIDENTIAL
PRINT
CLEARLY NEW 0 RENOVATION:cg REPLACEMENT:0 PUNS SUBMITTED: YES 0 NO❑
FIXUTRES'1 FLOOR-• Bsmt 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
GENERATOR Y
GRILLE ( : "" "w• �,
LABORATORY COCKS ---- _,._
. .
I
MAKEUP AIR UNIT
OCT 09 201
OVEN
POOL HEATER -
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST X -
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCOVERAGE
I have a current liability insurance policy or Its substantial equivalent which meets the
requirements of MGL Ch.142 YES [a NO 0
If you have checked yEs please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY I;Y OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I ant aware that the licensee does not havq the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waves this requirement. ,
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that al of the detals and Information I have submitted(or entered)regarding this application are hue and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit Issued for Iib application will be In compliance withal Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTERNAME I Kt nrte_kin p [lane ILICENSE#II.5415 I SIGNATURE
COMPANY NAME LSa fici r„!(, Get 1 ADDRESS:176 Green v. If f bri uc I
CITY: I c Pes+-cict(t I STATE: IMII 2IP: ( n, 6'-(K I FAX I I
TEA;15-OR 5-39-01 D) ICELL: �7.f.'� i EMAIL I -i—y;ydl (B rnSN tcover I
MASTER IR JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0#COPARTNERSHIP 0#J_1 LLC 0#
ROUGH GAS INSPECTION NOS
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
0,h1- 6/I3 ow aPii idl`7 /¢ Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: S PERMIT t
PLAN REVIEW NOTES
a
COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL LICENSURE?BOARD OF
PLUMBERS AND GASFITTERS
LICENSED AS A MASTER PLUMBER
ISSUES THE ABOVE LICENSE TO: I r
KENNETH P DEANE o
70 GREENVILLE, DRQ
FORESTDALE MA 02644-1006 I
15415 05/01/14 171685 I
LICENSE NO2- EXPIRATIONDATE .SERIAL NOS •
•
M