HomeMy WebLinkAboutBLDG-25-317 i/f,gef-
_sC.., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
n- f CITY: .F ��( / MA. DATE: 3S--)- — PERMIT#,36 �S-317
JOBSITE ADDRESS: �i5,�{�/////L,ff/ OWNER'S NAME: '�!-l$R
G OWNER ADDRESS: �_,.- G>� TEL:-77c 22-/3 FAX:
TYPE OR 'OCCUPANCY TYPE: COMMERCIAL{{ EDUCATIONAL❑ RESIDENTIAL❑
PRINT �/
CLEARLY NEW:27 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO LJ
APPLIANCES) FLOOR-. Burnt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
k.l INFRARED HEATER
to LABORATORY COCK
MAKEUP AIR UNIT
a OVEN ✓
'i POOL HEATER
ROOM I SPACE HEATER H C F 1 V F D
.I ROOF TOP UNIT (/15(� ✓
iii-
Z UNIT HEATER _ JL1N J 5p' ,
1L UNVENTED ROOM HEATER
WATER HEATER
t3UrLUINC,UENApN I MEN f
INSURANCE COVERAGE /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO❑
If you have checked 115,please Indicate the type of coverageerge by checking the appropriate box below.
LIABILITY INSURANCE POLICY�Q 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 ., ,and that my signature on this permit application waives this requirement.
• CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE 0' ER OR AGENT
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hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and a to to the best of my
Knowledge and that all plumbing work and installations per omred under the permit Issued for INs application will s- with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � f�
PLUMBERJGASFITTER NAME: I-, . .1 r J ICENSE# ZZ, a SIGNATURE
COMPANY NAME: II ` ADDRESS: /_+_
CITY: C t--j?t STATE:-4P. ZIP:✓/_ FAX:
TEL:7 'Z``�7_,,._�.CELL: EMAIL: s 3c t e @ re ,-/e--:s., t 1K7,e
MASTER ErJOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
c/ iyi ADDrzesS:-_
Jas'e_, c(jinc6c?, )1/ 1-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT S
PLAN REVIEW NOTES
4
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. . .
COMMONWEALTH OF MASSACHUSETTS
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
MASTER GASFITTER
JOSEPH C JASIE JR
16 APACHE DR
YARMOUTH PORT, MA 02675-2102
3422 06/01/2026 583438
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER