HomeMy WebLinkAboutBLDG-23-9612 CI( 1 ff l 9
fAl MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'-5-SV °� CITY S" ar . MA DATE r C d I I a
.- :^ I I 3 PERMIT �(U�-Z3' /
JOBSITE ADDRESS 34 m4Dornoff( ea- OWNER'S NAME ,. 'ck.kane
OWNER ADDRESS S m ON t TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:®. PLANS SUBMITTED:YES 0 NO
1
BOILERCES 7 FLOORS-, SSM 1 2 3 9 5 6 7 8 9 10 11 12 13 iq
r
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER - -
FIREPLACE
FRYOLATOR - -
FURNACE
GENERATOR -
GRILLE
INFRARED HEATER -
LABORATORY COCKS ___f
MAKEUP AIR UNIT
OVEN -
POOL HEATER 1
ROOM/SPACE HEATER
ROOF TOP UNIT —- R-E e E IN E B
TEST -
UNIT HEATER
UN VENTED ROOM HEATER OCT 20��
WATER HEATER
entr
OTHER - 11
-
a,' -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY,g] 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
SIGNATURE OF OWNER OR AGENT
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 compliance th all Pertinent provision of the
yt Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# a 7Ss SIGNATURE
MP 0 MGF 0 JP JGF 0 LPGI❑ CORPORATION❑# PARTNERSHIP 0# LLC 0#
COMPANY NAME -.1ck Kam Wove froc4inf ADDRESS 3el Moo°rnoy Ror'
CITY S 10 rrK STATE Plc, ZIP O166r/ TEL St/a-b8S-S61'6
FAX CELL EMAIL Jkat)terfg-0 yyh00.CC'f" '
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT ti
PLAN REVIEW NOTES
9 COMMONWEALTH OF MASSACHUSETTS
DIVISION OF OCCUPATIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN PLUMBER
i
!,1HN KANE
MONOMOY RD
S YARMOUTH,MA 02664-1984
22755 05101/2024 217787