HomeMy WebLinkAboutBLDG-24-345 t2I .= MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-1 CITY .SOL3111 Y 1-42-4 ya MA DATE -S-3I-2
y PERMIT((^^ #S7 .; 3
JOBSITE ADDRESS Si cpT far Q r S.yi.tr•700�OWNER'SN.AME-CchAi�
G OWNER ADDRESS 5`I Ce,2_ Or . Av4Z W,Q0)C 01(3? TEL(a/)--3YO-to'jrjfi FAX
TPT
YPE OR OCCUPANCY TYPE COMMERCIAL 11EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑
PLANS SUBMITTED:YES 0 NO 0
APPLIANCES-1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 11
BOILER
BOOSTER
CONVERSION BURNER _____________
COOK STOVE
DIRECT VENT HEATER
DRYER _ -
FIREPLACE
FRYOLATOR
FURNACE X ----
GENERATOR - - _
GRILLE 1
INFRARED HEATER _
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
R E C E F V1 J-€ b
ROOM/SPACE HEATER
-ROOF TOP UNIT C!�
TEST .. �Me 1
24
2
0 UNIT HEATER
UNVENTED ROOM HEATER Ft-A. =V
J WATER HEATERnv_�__
6 OTHER
O
NCE COVERAGE D I have a current liability insurance policy or its substantial equivINSUalentwhich meets the requirements of MGL Ch.142 YES 0 NO
00 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW El
9
VT LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
,,,I 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.
U CHECK ONE ONLY: OWNER a AGENT ElSIGNATURE 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 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 compile v4 a Pertinent provision of the
,� Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME-C-i-kNc�; (Zorn LICENSE# 253-03., SIGNATURE
MP❑ MGF 0 JP"JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME ADDRESS
CITY STATE ZIP TEL
FAX CELL
EMAIL
SOUGH GAS ySPECTION NOIE,S THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERPe11T ❑ ❑
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FEE: PERMIT fI
PLAN RFYIE 'NOTES
IMI•O . . • •• • •:::
DIVISION OF OCCUPATIONAL LICENSURE
.......BOARD.:•OF
PLUMBERS AND
• ISSUES THE FOLLOWING LICENSE ••••• . :
:•:': :••JOURNEYMAN PLUMBER
ce
.• • •
•• FRANCO A ROMERO 1
AVE
•••:- WEST ROXBURY, MA 02132-78414..,
25707
5
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::::::••• . 606843 •
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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