HomeMy WebLinkAboutBLDG-23-9632 MASSACHUSETTS UNIFORM APPLICATION FOR A PER f T TO 1j ,ra. ..F4 PERFORM GAS FITTING WORK
-,,,, ~v` hnr, DATE • PE-GAT
JOBSITE ADDRESS A-,07— Ss6y/�� 'fit rr 2 1 Z�- ,
GOWNER'S NAMEGv - i
OWNER ADDRESS 1t" TTEL 3/ 1 �7
TYPE O FAX
PRINT OCCUPANCY TYPE COMMERCIAL r
CLEARLY ❑ EDUCATIONAL ❑ RESIDENTIAL a.
NEW:❑ RENOVATION: ❑ REPLACEMENT:
PLANS SUBMITTED: YES❑ NO 2'
APPLIANCES T FLOORS-4 BClui t 7
BOILER - 4 5 6
BOOSTER 9 11 =® 13 14
CONVERSION BURNER
COOK STOVE -
DIRECT VENT HEATER
DRYER --- i'
DIRE
Ell
FIREPLACE i
• IIIII MI 1
FRYOLATOR
FURNACE
GENERATOR
GRILLE ______- - - ��I
INFRARED HEATER —y LABORATORY COCKS =----�
MAKEUP AIR UNIT
GOON - MINIM 1
i
POOL HEATER
-_
ROOM;SPACE HEATER --
ROOF TOP UNIT natenrongan_
•
TEST . .
i
UNIT HEATERIM
UNVENTED ROOM HEATER
WATER HEATERw.„,..sa,
OTHER
Meal ______
MI in
INSUANCE
ERAGE
I have a current lia zili insurance policy or its substantial equivalent which CVmeeets the requirements
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOWGh.12 YES ] NO 0
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND
OWNER'S INSURAINCE 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 Walive�this requirement.
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SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ] AGENT
`'.f:• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate
and that all plumbing work and installations performed under the permit issued for this op lication will be in compliance '
Massachusetts State Plumbing Code and Chapter of the Winer I Laws. to the best of my knowledge
L`j p with all Pertinei t provision of the
PLUMBER-GASFITTER NAME r Y t I�qi�°L At eS cr IC
LICENSE# SIGNATURE
MP❑ MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATIONp
❑# P;rO P- PARTNERSHIP❑#
COMPANY NAME r 2 k� LLC❑
ADDRESS ciA �/� �/
CITY �"�' ,�4 n�,S � "�
STATE ZIP Z
FAX TEL d ��
CELL EMAIL
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• NI• 'LTH 0 F PA.'SSA7-77'
OF OCCUPATIONAL LICENSURTTE
BOARD Of:
PLUMBERS ANOGASFITTERS:.'
....... _ .....' :.:,.,. t
.„::::''''i.• ...,.:. ISSUES THE FOLLOWING LICENSE
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... ..:.JOURNEYMAN PLUMBER .::2'111
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MIOHAEL R MCBRIDE--''':.•''''
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.,•:.....-:,...:.',4:AUBTIC DR
WEST YAPMOUTH,"MA 0267;4851 z. r Ill 19681 .. '...:.. ... 0S/01/2024 .. 262082 '''''"f
LICENSE NUMBER EXPIRATION DATE ' SERIAL NUMBER
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