HomeMy WebLinkAboutBLDG-24-61 MAS�SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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I MA DATE C
PERMIT
JOBSITE ADDRESS (J 41 444-5 /21) ~/-
OWNERS �� r� yr7C__-
OWNER ADDRESS TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:8n PLANS SUBMITTED: YES 0 NO
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APPLIANCES-1 FLOORS-+ SW 1 2 3 4 5 6 9 10 11 12
B 13 1,OILER
BOOSTER - -
CONVERSION BURNER
COOK STOVE
-
DIRECT VENT HEATER
DRYER t ,'
FIREPLACE IREC -I V7- D _
FRYOLATOR !
FURNACE
GENERATOR t 3
GRILLE -1
INFRARED HEATER ,U Lo NIL Uo PART,,MLNT -
i
LABORATORY COCKS
MAKEUP AIR UNIT - -
OVEN -
POOL HEATER
ROOM/SPACE HEATER -
ROOF TOP UNIT - ,
TEST -
UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142 YES a�u NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
• OWNERS INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Masser- setts
General Laws and that my si natur n this permit application waives this requirement.
CHECK ONE ONLY: OWNER® AGENT ❑
ti SIGNATURE OF OWNER OR AGENT
‘4, 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 compliance wl all Pe'nent pr visio 'the
Massachusetts State Plumbing and Chapter 142 of the�, CodePt General Laws.
PLUMBER-GASFITTER NAME LICENSE#/3 7 7 SIGNATURE
MP IIR5 MGF 0 JP 0 JGF 0 LPGI CORPORATION❑# A,RTNERSHIP 0# ❑#
COMPANY NAMEU✓�'1"'"L 11- ,�.j -, ,7I/7/ADDRESS � LC
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CITY ( 0--U�- STATE ZIP 00 3_?r/l �
A/ TEL , 0ed 3 IL/-0)3a
FAX CELL 547-- EMAIL '0-,Y c.c ryc 1., 4�_es 6 A- q r
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No •
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: $ PERMIT# •
PLAN REVIEW NOTES
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• di ONWEALTH OF SA HUS
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
• PLUMBERS AND GASFITTERS
• ISSUES THE FOLLOWING LICENSE
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MASTERUMBER
MARK G REDDAN 0
•
-• PO BOX 173 t;
CARVER, MA 02330-0173 w
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LICEN NUMBER ,
. I •
EXPIRATION DATE SERIAL NUMBER •
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4;;ON'a"--rfo 110N H OF MA ACH US
DIVISION OF OCCUPATIONAL LICENSURE
BOARD Of
. .
PLUMBERS AND GASFITTERS
4- 4
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN PLUMBER
MARK G REDDAN
PO BOX 173
CARVER, MA 02330-0173
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2:709 • • • :4.: • •
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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