HomeMy WebLinkAboutBLDG-15-000071 MASSACHUSE i i S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: W tfrvier v74 Mk DATE -2-"2 Z -/! PERMIT r 7/'' — 0 7/
-L--,-, JOESITE ADDRESS: '33 rJ'ySch U 674 OWNER'S NAME Tecivi f S(
OWNER ADDRESS: TEL FA
TIDE OR OCCUPANCY TYPE COMME:CIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PR1\'T
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:X PLANS SUBMITTED: YES❑ NO❑
I APPLIANCES? FLOOR-4 Bsrnt 11 12 3 I 4 I 5 I o I 7 I 8 9 I 10 I 11 12 I 13 I 14
I BOILER I I
BOOSTER I I I I I I
I CONVERSION BURNER I II I I I I1 1 I I
COOK STOVE I ( I I I I I I I I
DIRECT VENT HEATER i I ( I I I I 1
DRYER I i I I I I I
FIREPLACE I I I I I i I
FRYOLATOR I I I I I I I I
FURNACE
GENERATOR I I I I I I I
I GRILLE
INFRARED HEATER I I ! I I I I
I LABORATORY COCK I I I I I I I
MAKEUP AIR.UNIT I I I ! I I I I
I OVEN I I I I I I I
I POOL HEA I EK I I I
ROOM/SPACE HEA i EN.
ROOF TO°UNIT I I I I I
I I i I I I I I I I
I U IIREETBE b I V E I ! I I I I l I
lU % R 1 I I I I I I 1
I W i HEA L:i- y I I I I I I I 1 I I
JUL. ,) 1 I 1 I I I 1 1 I I
II 1 I I I I 1 I I 1 I
I Ri1ILDING D RMEN 1 1 1 I I 1 1 I I 1
I By - INSURANCE COVERAGE
I have a current liability insurance policy or its substritial equivalent which meets the requirements of NIGL Ch.142 YESV NO D
if you have checked YFS please indicate the type of coverage by checking the appropriatz box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER I am aware that the Iicensee 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 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information 1 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 begin compliance with all erth
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � .;%/
PLUMBER/GASFIT GASFITTER NAME Wi ( re1(Gt-e-C�/�' 6 LICENSE#/3 GNATURE
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COMPANY NAMETM,t I oze(c,c.-.s P(_6 vt (+7-6 ADDRESS: - cAr/S5 Jvst & ��
CITY: r� L k 0 c'Z4 STATE:MJ'I ZIP: C1.- 3 6z) FAX:
TEL: CELL: .77/- 706 hoe EMAIL:
MASTER JOURNEYMAN❑ LP INST" I 7 CORPORATION❑ P RT NE CHIP 7= i t C
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v ;.COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS 1411
y.n '_ ISSUES THE FOLLOWING LICENS
LICENSED AS A .MASTER PLUMBER
MICHAEL L KNEELAND
59 CLARISSAJOSEPH RO
3
P. ' MOUTH MA 02360-6912 •
1 210. 0 01 ::16 212 8•
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER