HomeMy WebLinkAboutBLDG-18-007358 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,1_- CITY y a r N.��1'4-- MA DATE C I Z 7 1 I'7 PERMIT#*06-4'0 715r
JOBSITE ADDRESS 15 g --?›c r rr y, Av( W• '1.-r kC' -- OWNER'S NAME Iz^A- C'"c c
GOWNER ADDRESS 7 0 1 E- ��/S� g s ram` TEL b 17 - y. e- J F" ,
TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINTCL ❑ ❑
EARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO ❑
APPLIANCES-1 FLOORS--4' BSM 1 2 3 4 5 5 7 s 9 10 111 12 13 14
BOILER
BOOSTER
CONVERSION BURNER.
COOK STOVE —___,
DIRECT VENT HEATER i
_
DRYER
FIREPLACE _______,
FRYOLATOR '
FURNACE
GENERATOR I
GRILLE I
INFRARED HEATER I
LABORATORY COCKS • i
MAKEUP AIR UNIT I
OVEN i
POOL HEATER I
ROOM I SPACE HEATER CeaC
I
ROOF TOP UNIT 11
TEST . .
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
( I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COV 'GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IR 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 ❑
SIGNATURE OF OWNER OR AGENT 1
't 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 co ta ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter"142 of the General Laws.
PLUMBER-GASFITTER NAM' LICENSE# 5.---
GNATURE
MP ❑ MGF❑ JP [ JGF❑ LPGI 0 CORPORATION 0 IF PARTNERSHIP D# LLC
COMPANY NAME C 5.(d' pI-.-.‘r^ 1 ;-�-r- ADDRESS /� AS `i� ✓v g J
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CITY �^r n C / StA E (1 4) ZIP 0 /Ei 7 TEL 6 /7 - Y O -- .3 if?
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COMMONWEALTH OF MA__
` °r10N'`OF PI�OFESSIONA LICE ETTS
BOARD OF S11�iE�:
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN PLUMBER
PATRICKr"CAPER
15 AGAWAM RD
QUINCY
MA 02169-2413
W
U
31638 05/01/2020 J
462974
SE:NUMBER EXPIRATION-DATE w
'SE•T'11N. MBER