HomeMy WebLinkAboutBLDG-17-006138 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j
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1'�ki�,��' CITY �I/eS� �l/�z t/l,W�/7� h4A DATE ��- ��-� � PERMIT#A/�l7'-17-l�O(P(✓
JOBSITE ADDRESS ti0 xi/ 'mac OWNERS NAME 1 7 Q 5 —7xii4 9 G
OWNER ADDRESS fel en t TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL'
PIT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:5 PLANS SUBMITTED: YES❑ NO l
APPLIANCES I. FLOORS-4 2
6,�IJ� 13 4 5 5 9 10 '11 12 '13 14
BOILER .■■
BOOSTER
CONVERSION BURNER
COOK STOVE -`
Inli .
DIRECT VENT HEATER ��
DRYER j
FIREPLACE f
FRYOLATOR
FURNACE
GENERATOR
GRILLE I
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER ' ' 0
ROOM I SPACE HEATER
ROOF TOP UNIT italTST _ _ 1--
• IT HEATER
UNVENTED ROOM HEATER I
WATER HEATER I
OTHER '
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1
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO a
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ I
tOWNER'S INSURANCE WAIV . 1 aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Gen . .aws,ar that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER /, AGENT ❑
•-. SIGNATURE OF OWNER OR AGENT
711- I hereby certify that all of the details and information I have submitted or entered regarding this application ar- •- -nd 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 F• • ce with all Perti ent provision of the
N Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# ayii.7, SIGNATURE
MP❑ MGF❑ JP tg JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC 0#
COMPANY NAME A!V C0.30 194 il ADDRESS A
CITY fA 5� A4Q r -- STATE ZIP 015 6 P TEL
FAX CELL 505 113 ,2i'% EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
FINAL INSPECTION t lta'i'I';S
%/ THIS APPLICATION SERVES AS THE PERMIT Yrij
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C'/ FEE: $ PERMIT tC
PLAN REVIEW NOTES
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COMMONWEALTH OF MASSAHUSETTS....:;
DIVISION OF PROFESSIONAL LICENSURE
BOAR;*-
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
LICENSED ASA JOURNEYMEN PLUMBER cc
Q
DANIEL E COBB
E.MAIN ST
WESTBOROUGH,MA 01581-1468
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30042 '05/01/2018 42346
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER