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HomeMy WebLinkAboutBLDG-23-9378 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM t_,:r (s GAS FITTING ��,—(=r•��Jai WORK�'.oc CITY_yu�N© 'r [ OIZi ''` MA DATE L- 2/-�jZ 3 JGESITE ADDRESS ,�r..attA Y ��R�K 2� PERMIT# (.,% •� _ ��� G / ��"tV-r OWNER'S NAME . t i2i toy,► OWNER ADDRESS �C�1r`�G�j; (` S�? �1A �� TYPE OR / TEL -r1G>_G !3 PRINT OCCUPANCY TYPE FAX COMMERCIAL kj EDUCATIONAL CLEARLY ❑ RESIDENTIAL 0 NEW: . RENOVATION: ❑ REPLACEMENT:0 APPLIANCES PLANS SUBMITTED: YES❑ N0�' BOILER FLOORS-4 ssk a ©®0�©® BOOSTER -® ®® 13 14 CONVERSION BURNERmin ' COOK STOVE v DIRECT Mrrillal -- DRYEP, 1ENT f lEP,TER --in FIREPLACE v -�-- FP,YLiLATORILIFEIR inn GRILLE —� _— unman ��- INFRARED HEATER11111iir __— LABORATORY COCKS MAKEUP AIR UNIT v - POLL HEP,TER 111111111.11111111111. �Wv MIN MINI vv=— —'1 ROOM I SPACE HEATER _ ROOF TOP UNIT TEST , UNIT HEATER rill ®- �" .UNVENTED ROOM HEATER `�i` , � D1iNATER HEAl'EFt _ •/�il`' i , peta ani soli 1111111 i Mill ___________Immam policy have............im I aINSURANCE _� current liahlfi insurance COVERAGE �__ - _� !� y or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES j NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ' LIABILITY INSURANCE POLICY • OTHER TYPE INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. v '-\ SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER I hereby certify that all of the details and information I have submitted or entered regarding this applicationAGENT ❑ I ande that alle certify plumbingthat work 0 and installations performed of the the permit issued for this application will be in compliance w' 01{ eminent provision o' that ,.bate work CodeP are true and accurate to the best of my knowledge Z Plumbing and Chapter 142 of the General Laws. PLUMBER-GASFITI"ER NAME �-, of the ,-� s i - INP ❑ MGF LICENSE# ZZ JP ❑ JGF❑ LPGISIGNATURE v- 0 CORPORATION❑ P COMPANY NAME PARTNERSHIP 0�� LLC c 4 � ❑ CITY \ 74.t' ADDP,ESS �, r< r FAX STATE ZIP c? - CELL � �> TE --'_..-�--Z�� _ EMAIL i t ,d 3.L DIVISIONOF OCCUPATIONAL'LICENSURE BOARD OF PLUMBERS AND GASFITTER$>. ISSUES THE FOLLOWING LICENSE MASTER GASFITTER gI g JQSEPH C JASIE JR 18 APACHE OR YARMOUTH PORT MA 02875-21 p2 Val 3422 05/01/ 20z4 218774 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER • • • • r