HomeMy WebLinkAboutP-14-943 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
• CI1:rty�� (/y000(/`t q �MAj ,DATE l��°�1� PERMIT Ply %1�J�
' JOBS ADDRESS- l 0 S/ cr 2+�rf ` I'^"^ ` OWNER'S NAMEArr
G OWNER ADDRESS: S-10C TEL0i- in'??70 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL,'
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACBarriEL PLANS SUBMI I I EU: YES❑ NO(ar"
I APPLIANCES? FLOOR-+ Ssmt 1 1 2 3 4 5 6 7 1 8 9 10 11 12 1 13 1 14
BOILER I I
BOOSTER I I I I ,
CONVERSION BURNER I I
COOK STOVE I I
DIRECT VENT HEATER
DRYER I
FIREPLACE I I.
FRYOLATOR
FURNACE � I I
GENERATOR
GRILLE 1
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNI I
OVEN I I I
POOL HEATER I • I
ROOM I SPACE HEATER 1 I I
I ROOF TOP UNIT I I I
TEST
I
UNIT HEATER I I I I A I
I UNVENfED ROOM HEATER L
�...��W�ATTFFP ''EA 1,_r< I I I G�� ' 0
W C1 I I I r�r. il�l �Ul l'.- ��;��I
I - I I III�I a Is L IIIII
W t� rail 1!!�711EMIiihi I
c INSURANCE COVERAGE VII , ' 1111 IW
z a I h current Lila!' insurance policy or its substantial equivalent which meets the requirements . I L (12n
1I7� ►' Li I■
r�cr -a 1 $1a1°'E, -1
L+o o If y�,ve checked YES please indicate the type of coverage by checking the appropriate box below
K�v � M LIABILITY INSURANCE POLICYg OTHER TYPE INDEMNITY 0 =OND ■
'\ 1c UWNtJ'S INSURANCE WANER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
`Tra„aLnusetts General Laws,and that my signature on this permit application waives this requirement.
cbl CHECK ONE ONLY: OWNER ❑ AGENT 0
�a SIGNATURE OF OWNER OR AGENT -
e
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 Nassachusetis State Plumbing Code and Chapter 142 of the General Laws. _
PLUMBER/GASHI I txNAME4(&K /ffC CWrllf'024 C LICENSE#377r SIGNATURE
�
COMPANY NAME: f1Ct'Q4Vf//.fl1 1.11/4,-441,1 Tilt ADDRESS: 32GG p�gsnz Ctnw41 red,
CITY• p(tn11A,i S ia""r STATE y Vt ZIP: o 3 / • FAX
-EL77¢'2(2 ' 277S G6.0 Ea ?uter-fecv co.,re .verf—
MASTER)2 .-JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 a PARTNERSHIP❑.i LC 0#
1- W
7,
OUGET ,A i SPE " • N• V' huSPAGI:Foil INSPECTOR USE ONLY 1'1NAL INSI'CCJ'ION NOTES
i Yos No —
TRIS APPLICATION SERVES AS TME PERMIT 0 0
FEE; $ ' ; PERMITA
1:: z
..>:
�11AN1iPVIL11'NO'1'1S _
—_____
, i
•
• I :COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL'LICENSURE F BOARD OF
PLUMBERS AND GASFITTERS
-LICENSED AS A MASTER GASFITTER _
ISSUES THE ABOVE LICENSE TO: '1
ALEXANDER H MCWILLIAMS 1m
386 LOWER COUNTY RD �� '
{
DENNISPORT MA 02639-1514
3775 05/01/14 189206• ' 6
OluaNSENO. }r,'g"'EXPIRANON DATE] "BERIAL NOM