HomeMy WebLinkAboutBLDG-23-9469 �'�'' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�I ,e CITY Ycii''M e LJbi— MA DATE 9/ i / 3 PERMIT
JOESITE ADDRESS I S o 16 u,',j . cJ OWNERS NAME D'C'Pc-- ' 6-1,A!1‹:Ni
OWNER ADDRESS . �t . TEL 7)LI 4 7''[ I+{L� FAX /`
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ ,�SIDEJTIAL�PEA
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES 4 FLOORS—+ BEM 1 2 3 J1 5 6 7 8 9 10 11 12 13 1,
BOILER
BOOSTER
CONVERSION BURNER -
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRY CILATOR — 1
FURNACE
GENERATOR
GRILLE
INFRARED HEATER —, ---_
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN - -
POOL HEATER • fil E E: iti 1---_
ROOM I SPACE HEATER -.-
ROOF TOP UNIT —_1
i 1 SEP1 d �
TEST
UNIT HEATER
UNVENTED ROOM HEATER BUILDINb UtHAR I Mt
WATER HEATER -~ ur_—
—®�
OTHER ,
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES ,NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE 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 waives this requirement,
t.
., CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
'I• 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 f my knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with au,Pe ' r/ov/isiion of the
Massachusetts State Plumbing Code and Chapter-142 of the General Laws. -�� ✓
PLUMBER-GASFITTER NAME ��ro)0,0 ) u r -►5 '3- LICENSE# ) 3 Ic1-!i( SIGNATURE
MP ❑ MGF❑ JP JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#!:
COMPANY NAME P, I�f iM dta re.5 ADDRESS 1(�D Li.),a,,S i--c.al
CITY >-1-v nn.$,r 2 3 c,,,c-j., STATE At & ZIP b '6 192 TEL
FAX CELL 3 L( rry a; k EMAIL ,A(LC 9` c),r-'fr}1-5 6 ema_r) 4 rm:,.,
Fold,Then Detach Along All Perforations
„„.
DIVISION OF OCCUPATIONAL LICENSURE
13,04R011.W
PLUMBERS AND'GASFITTERS'...:
ISSUES THE FOLLOWING LICENSE
g'.'..•..::.JOURNEYMAN PLUMBER
GORDON P TURGISS JR
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•:• 160 WILLISTONAO'
SAGAMORE BEACH,MA..:,0254g4t3e
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••• 31843 05/0112024., 259708
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LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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