HomeMy WebLinkAboutBLDG-17-000047 . ,
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1. 6,15;tei.(3
VtiV7:P CITY SO-5(*YAN51_,X-1.(2 01:\1k, MA DATE 1 - (0 — /Cc> PERMIT#/657
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JOBSITE ADDRESS 8 6-5t\--•-0-1,---0r-Iv- (j -t OWNER'S NAME 't 0 t'—‘L1,6.. C-. A..1 P-5 C-4
GOWNER ADDRESS s 9 vo.cfat_ G , TEL FAX
TYPE OR 6L4.1....)V- -V In a. .PRINT EDUCATIONAL 0 Ei OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION: R:I/ REPLACEMENT: Er'.--- PLANS SUBMITTED: YES 0 NO Ei
APPLIANCES 1 FLOORS--+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER I
FIREPLACE I
--- I
FRYOLATOR _ .
FURNACE
GENERATOR
GRILLE
__ __T
INFRARED HEATER , 1
, I
LABORATORY COCKS
MAKEUP AIR UNIT I
, -
OVEN I
' I
•POOL HEATER
--I____
ROOM I SPACE HEATER i
ROOF TOP UNIT
TEST
-1--UNIT HEATER ,
UNVENTED ROOM HEATER
WATER HEATER __1_ I
OTHER _
i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES e10 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0, OTHER TYPE INDEMNITY 0 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.
CHECK ONE ONLY: OWNER 0 AGENT 0 1
SIGNATURE OF OWNER OR AGENT I
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur te to the best of m cnowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compile •th Pertinenh of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE 4.f.Z. 51 SIGN URE
MP 0----MGF E JP 0 JGF 0 LPGI CORPORATION 0# PARTNERSHIP 0#
0LLC ci#
COMPANY NAME AA)Nke_14) ei 1-.S`e Al ADDRESS RECEIVED
CITY A40d,p1 STATE/0 I ZIP 67)... to t TEL I
j
FAX CELL 1.-Cif0"--2*/( EMAIL _ JUL 06 2016
a suitwiNc DEPARTMENT
air ,22,._._yeepc - 27.2-
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r
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
j I
v COMMONWEALTH OF MASSACHUSETTS
DIVISION OF PROFESSIONAL LICENSURE
• BOARD OF
PLUMBERS AND GASFITTERS
• ISSUES THE FOLLOWING LICENSE
LICENSED AS A JOURNEYMEN PLUMBER \
ANDREW L NILSEN
10 RESERVOIR DR
RANDOLPH,MA 02368-3140 (4
0
16353 05/01/2018 45470
UCENSE NUMBER EXPIRATI* •ATE SERIAL NUMBER
V COMMONWEALTH OF MASSACHUSETTS
• DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE %
LICENSED AS A MASTER PLUMBER
ANDREW L NILSEN
10 RESERVOIR DR
RANDOLPH, MA 02368-3140
0
•
8351 05/01/2018 45464
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