HomeMy WebLinkAboutBLDG-24-253 - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'_
=�'—"� CITY Sac.µ, Yu.�,,; �
MA DATE PERMIT#
JOBSITE ADDRESS tI 5-7- /44;,- Sir Lt.), f Su,44, ` narIL. OWNER'S NAME(
G Y�C
OWNER ADDRESS Li 5 3- tick:.n Si-cu,� 1 y„i Yum60-r, TEL FAX
TYPE OR —�_
PRINT OCCUPANCY TYPE COMMERCIAL� EDUCATIONAL 0 RESIDENTIAL 0
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:L7 PLANS c
SUBMITTED:YES 0 NO[�
APPLIANCES 1 FLOORS BSM I 2 3 4 5
BOILER 7 R 9 10 11 12 13 14
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE I
FRYOLATOR
FURNACE R F �� -r
GENERATOR 1•.
GRILLE r
INFRARED HEATER i, I_ A-PR _7
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN L
POOL HEATER _
•
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST _
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER _ _ _ _
OTHER TLSC-o, y4sF:p,,,j t , _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 2(1;O❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
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. I
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 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 all Pertinent provision of the
L1J Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME A-h,) ram; tADIA-S LICENSE#R i 1 cl SIGNATURE
MP rEti MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# I1C❑#
COMPANY NAME PIaVlb i rlyJ $cI,)4-onl l3J 14Nt,ZS ADDRESS ‘9,P l�s4-;C LWIr
j CITY tIr cnn.S STATE HA ZIP 02 l,0 I TEL
FAX CELL -Pi-721-S 6 13 EMAIL tldm ,Q Incl..); ril l rgrfw r rv\
f:J
H
C)
L)
(at
Gil
-,11
ti
Cj w
o
H
H 0.
p.1
Cl)rr COcn ,L. y . ..
.. £
�I
fs us <C
ob
cx,
,� b4
U-
4I
C
r�
r
0
p�
V
1 Ih�
1V�1
r�p9
n7M
V
1
9, • k/ kJ_ ‘14 Al Li A A H SE
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTINIIII
ISSUES THE FOLLOWING LICIESSE
MASTER PUJIWIBER
ANDREWS C HAYES
22 RUSTIC LH
HYANNIS, MA 02601-4340
- .
- • LICENSE NUMLILY N iRI MF3FR
__ _ *
•
•
•
f
•
•