HomeMy WebLinkAboutG-15-2554 C. 1C .` MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
• .n Tr.. _-. :ii. • •• - —1 MA DATErY1i 4Tr17 -1PERMIT#IjLna/5= 0025,7
✓ = Isf- CITY , C ti's ,
JOBSITEADDRESS! IIs alaty 1A- • (OWNER'S NAME :
id-rt-,-3,j �ydcd/ _.,1
G OWNER ADDRESS - lrY sr� , i9/il/ p /T
1OpIGqf TEL .07.-70 fr99 ,FAX'
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL . RESIDENTIAL"_].
CLEARLY NEW:,j RENOVATION:.) REPLACEMENT:) PLANS SUBMITTED: YES'j NOL)
APPLIANCES 7 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _J!—J_J_)_J_!_I_1_1___I J—J_—I
BOOSTER ___I !!_J I .!'_j-J_IjJI__I! _
CONVERSION BURNER I I _I_ -J_I _J__J _____J_J!_
COOK STOVE I I_J____I_I—J—J! —_ _J_ __J_J—1_I —I___JDIRECT VENT HEATER _i_J.-1! I _1 _1 _____J !! __lc!_I-J ___I
DRYER _1_I _J'_J!-JI�I _1_ -1__i! _I!
r FIREPLACE —I—J!_I_l—I-J—! __I_J'__I_. i_I _J.
FRYOLATOR _!___I!'_J._l _1 _ I __I_I __I _ I _I_I_JJ—I
FURNACE _I—J _J'_J_l _J__J I __I—J _._I—1 .__I_1
GENERATOR
1R —_J_ _i,! I M! _I_—I__J ____I J_1
GRILLE __J;___J ___I I —1_J____I ___I ____I ___I—I_! —I_____IINFRARED HEATER _J____I_I _! I _�_I ____I _J _ I___I____I____I __.I
LABORATORY COCKS ____,J_J___! _-I I—1_,__J_J.__!__.__I_._I_J—I—I_J
tMAKEUP AIR UNIT I _ _;._ _I_ l!____J_J _1,1—J—I i_I
OVEN I ....___I.___I __I _I _!__J—I ___J —! I I I _i I
POOL HEATER —I_ J�! _1._J _I I_._-J —J __J.___._I_J.__J—J ____I
ROOM/SPACE HEATER _I—I.__J —__I —_I ___—_I_�1 _I _I _1 _I_I_I I
ROOF TOP UNIT
J _.I_____I — 1 _.._J
_I I_ _!__I..i_'___.1!_._ I
TEST —1�II_1T1 i_ !_I_i__L_J__—sI—! 1
UNIT HEATER _I I—J _ _J __I—J __J___J ___j __J ___I __J
UNVENTED ROOM HEATER• v., I __I 1 __.I____I _____! ____I —! _J__J !_—J __!___J
WATER HEATER „,:::_j_,,-_ -1_ I.__.J !,_____I_I_._I_J�J __I__I___1___1—I_I
OTHER) ,..3 / I I __JJ
. I I—i__I.—J_I __J—I _ . —J_i_1
�” • - ,. (Pv i' I _I _I •_J ' 1 _I ___I—1 _I —_J _J _J ._J.-1 I
it t t i - ° �--' ' i I-____I U___-I__-J_--...J -1 ___'___.I _—_I-_-�_!—c
♦ t I _._ I I _ .. I I 1 .... ,
Q " 1 M INSURANCE COVERAGE --.
EI have a current li di surance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES II NO s„I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J OTHER TYPE INDEMNITY '_,J BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Massachuse en/neral Laws,and t at signature on this permit application waives this requirement. '�r r i - atJz,-. CHECK ONE ONLY: OWNER AGENT °J
SIGNATURE 0 OWNER OR AGENT
I 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 rtine • c of the-
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME like t-vt sC G n 3 J' I LICENSE# IC59'a1 S
MP; J MGF f JP!_( JGF;,J LPG] , ,f; CORPORATION;,]# iPARTNE SHIP'_ 11#I ILLC i„_j#' ('
COMPANY NAME: IADDRESS7 IbZ'% Rac_e—1,--1- - -------
CITY MdSk-a.-1i M,' is ( STATE, MMAV f ZIP 07.te'-F8- TEL -9-4 Z12 flt1
FAX I (CELL EMAIL' -cc ' i'N I o (Z) VA- l . c o vA I
� f
•
S3.LON MaLA311 Mind
#11Wa2d $ :33d
0 0 MIR'3H1 SV SJAHJ3S NOIIVOIIddV SIHI /
oN saA '$9 7/ 'N?ft 21.4? W' -9021
Sa.LON NOIY73dSNI IVNI4 AINO asa}IO.LJddSNI ROA 3OVd SIU Sa.LON wouaaaSN1 svo IIOnott
,l
ji COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL LICENSURE
wrr a a, BOARD OF
.PLUMBERS;, AND GASFITTERS f
• ISSUES •THE' FOLLOWING L-(CENSE s4;,:
LICENSED AS A MASTER PLUMBER a
.THOMAS C GAV I N �F
49. 4771i,11:12
1629 RACE4IN` t 4111.5fr t
• as yrs - r a Se
MARSTONS M<LLS;MA 02648-109• 7 �'
6'7'7 15598$„ 05/01/16•rf<<: 221793
•
v COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL LICENSURE
°b.< BOARD OF
PLUMBERS,'AND GASF.ITTERS";
es:ys ISSUES THE FOLLOWING LICENSE s
•- LICENSED AS A JOURNEYMAN PLUMBS s
THOMAS C GAV I N `fz E ,I
1629 RACE'LN $ � � \�
4' aV ® F,
mA,RSTONS MILLS MA 02648-1097
3092t:12a „05/01/16 p,, ;;221794
g MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• iMt
lI= CITY :---Y61/4:r��A.��i o-;-V---_.-- 1-'-_-_-Ili .
MA DATE td ��CLf I�{ (PERMIT#
JOBSITE ADDRESS: 15 (A c ._5A • 'OWNER'S NAME : i,v '.9 --1
G OWNER ADDRESS :-27-71;52-2—C7-7/2,341-{A/A-1q /9k41441 TEL ST3,1 54119 FAX'
TYPE OR OCCUPANCY TYPE COMMERCIAL 4 EDUCATIONAL „J RESIDENTIAL3
PRINT
CLEARLY NEW:::_t RENOVATION:2 REPLACEMENT:,J PLANS SUBMITTED: YES EJ. NOD
APPLIANCES 2 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —J__J_j_)__i_J_I___2_I—IJ__J__J_. I
• BOOSTER i I !,_I_#_1_I _I_1_l J—.I_J - -I
CONVERSION BURNER • _I I_I _I J J I i -1 J'_J__J_I_J I
COOK STOVE JJ_JJ I____I__—_J____J ' . I_
DIRECT VENT HEATER _i I______J J J___1___J—1_l_.J_1
DRYER' J_____J _ii -J-J I I-1 -1_,I
FIREPLACE _..L-J_J _I_l_I__J_!__J_ !—1__I
JFRYOLATOR _LTJ J:_-___f_.-1_ _-J __I '. —I-_—I __I J__D I
FURNACE ._—I_J_-I I__I —I_I_ I_____I__J ..I I
GENERATOR
IR _I__i_J—L—I __IJ__i-1_—J—J
GRILLE Ji J_J--J—)_. ..I J—_ __.--I J'__J J—I
INFRARED HEATER __J_ _J I_ .-I'_ __ __!_1 J ,I
LABORATORY COCKS _I_'_--.i_;_ ____!,____I__-I__—.I___I. _J___I_J 1
MAKEUP AIR UNIT%tie
_f__ __—I_j-- J.J_ —!_—I1
OVEN —f__-_I____.!_I_�1'--.1_-..I_I __J_J _..J _-i____I _J—I
OOL HEATER _I_—I_J —J J__—I___!__!—I_J_.I____1_J_J-U
ROOM I SPACE HEATER _I_!,___J _I_ I,__I 1___!_I I_I_I_I i_i
ROOF TOP UNIT -.__I____-i_._—i—I I—_I_J__I___1 _i___JI__ " 1
TEST _I Z I I I ' I I I i I I ` I.__I—1 I c
UNIT HEATER _I_I_ ___I—, 1�I_J_I ___J_ I I •
UNVENTED ROOM HEATER ! —I ___[___I !--.1 !___I___J.__._J__I ..—I J
WATER HEATER I I_f__LI ^I_U_—J=1^I_—_U-__I 1 I I
_OT �fHER
_� 9".//,,�y I I i__t I_J—!_J I _I—J_ !_J`I-1
(Of!'
q t 1 .__ IJ�! _JI__! —!-1-1—!-1_J_I_j
__I—iJ —I__I_-_1_JJ--J_�L_J_—I -I
/2/ INSURANCE COVERAGE
E, d I have a current IiAtSilitvifisurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES I.1 NO,ZI
�? I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY _( OTHER TYPE INDEMNITY 'J BOND IJ
tm
` OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
tV Massachuse :4__-
eneral Laws,and at. signature on this permit application waives this requirement.
• aftter-k CHECK ONE ONLY: OWNER AGENT _.1
0 SIGNATURE 0 OWNER OR AGENT
I 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 dine o of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ry
PLUMBER-GASFITTER NAME 14tAksC l7•-.•J I LICENSE# 1559 ii I
Lrs MP. MGF ,.1 JP _ JGF LPG! �, CORPORATION # PARTNE SHIP_..1# I LLC _I#'j
` COMPANY NAME; IADDRESS• 11,37-1 (Z.•c_ 16--1 --- — -- - I
CITY rgS-'-d-s3 M;115 STATE fMIeIZIP 61e4-43 TEL' ri-44 1212 132°c
FAX (CELL IEMAIL: -cc Vkd;as 1 0 (41/49Mk11 . co✓•\ I
4
h
Li
- - - -
1