HomeMy WebLinkAboutBLDG-23-9718 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY \//r/ylru MA, DATE PERMITS
JOBSITE ADDRESS d/f Sheaj C.ik// OWNER'S NAME/�rp2� aPti va
OWNER ADDRESS S.:ii-r., TEL FAT_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ R SIDEIJTIAL�
YFrJNT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® :
SU
BMITTED:UBMITTED
YES❑ NO 0
APPLIANCES 1 FLOORS 6SM 1 2 3 4 5 6 7 4 9 10 11 12 13 14
BOILER I
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR - -
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
UNIT HEATER F gI
LINVENTED ROOM HEATER •
WATER HEATER
OTHER [ELI D
CJILD� a -k4F_NT
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES tg] NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY KI OTHER TYPE INDEMNITY ❑ BOND ❑
OWNERS 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.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and curate to e b of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in co with P nevision of the
Massachusetts State Plumbing and Chapter 142 of the General
�t CodePt Laws.
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP❑ MGF❑ JP JGF❑ LPGI❑ CORPORATIONEl It /PARTNN�ERSHIIP❑# //
/ e LLC❑#
COMPANY NAME i. GG
y ang/n16I-�/6 -104L. ��`7`a ADDRESS � , f/1Q�// /C.4
CITY �( / STATE /�4/ ZIP ,') L 77Q TEL
FAX CELL3?38-7;6-L7747 EMAIL // MO4c/i/e9/'J 4 0 6fx.j/, CO4k
ROUGH GAS INSPECTION NOTES THIS. PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES
DIVISION OF OCCUPATIONAL LICENSURE
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• ••• PLUMBERSANti s:GAtFITTERgio...u- • •
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ISSUES THE FOLLOWING LICENSE - •
JOURNEYMANF4,U0/1BER
•
NAT.HAN J DVORSKI • .! ...
• ••
ROCHOtt0;MA .0277.0-.1307 z
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33387 0510112024 262399
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LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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