HomeMy WebLinkAboutBLDG-18-002955 MAS ACMUSETTS UNEFDRNI APPLICATION FOR A P E MIT TO PRPORIVI GAS FITTING WORK
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JOBSITE ADDRESS l 85 6o AL Sta P t. OWNERS NAME �447 ig eft
OWNER ADDRESS TEL50a -115-1(,0? FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO
APPLIANCES FLOORS-4 c7 31 i
BEM 1 3 4 5 69 10 'I'I 12 '13
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER '
FIREPLACE —�
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER I
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER.
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER •
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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)1 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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑ I I
• 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 with all Pertinent i . .ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,�'
PLUMBER-GASFITTER NAME LICENSE# D7&o SIGNATURE
MP ❑ MGF❑ �IJP ❑ JGF u ' g C
LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME HOOSAkitu ► etkA t S SUS ADDRESS / J(ioi Yr
CITY Wm Ocito STATE Mil ZIP C 247 TEL �71 31 1 000�
FAX CELL jD� 2-116 `3t- - EMAIL() l,ernc6044c//1a-tecrlC4(.05144,
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION t IOTEg
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
MASACHUSETTS p s
it taste WORE $43784870
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COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL:LICENSORS
OF
PLUMBERS AND GASFiTTERS
ISSUES THE FOLLOWING LICENSE AS A
UCENSEO JOURNEYMAN GASEITTER
JAMES E MCDONNELL
18 ARROWHEAD DR
WEST DENNIS.MA 02670-2706 Y.
5076 - OSIOt7201S 55578
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