HomeMy WebLinkAboutBLDG-17-003367 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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i . 11,E CITY S . 1 n vt}N MA DATE I0)- -e "IL. PERMIT#oat3"/7-C c) y` 7
JOBSITE ADDRESS It"ttkIr i►i A4e OWNER'S NAME Cd t
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL'
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CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO/
APPLIANCES 1 LOORS-+ 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
_FIREPLACE � ,
FRYOLATOR
FURNACE
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GENERATOR 1N.A.L 1 t� nN cciii ,
GRILLE —_
INFRARED HEATER _ a ��Q"! ._
LABORATORY COCKS
MAKEUP AIR UNIT r,,. 1 '
OVEN 0 3 6 3 3 U
POOL HEATER ----
ROOM I SPACE HEATER
ROOF TOP UNIT
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 MGL.Ch.142 YES ' NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER:I am aware that the icf ensee 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
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 with all P rent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1
PLUMBER-GASFITTER NAME 13 i I(/ tit 1.S LICENSE# 3 q Lid- 1, TS�SIGNATURE
MP MGF JP JGF� LPGI CORPORATION # , +PARTNERSHIP # LLC #
COMPANY NAME: Pt l l Y!!! �,JC!r t p 3 ADDRESS 9 F k i to T�L
CITY .So,hel1,.it-Ii 1 STATE fpfj- ZIP 0.},31, 3 TEL. -]1y' a1,61' i7'l'
FAX CELL EMAIL 13 Rol ml5 1-, v yc I- 'aril
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¢ COMMONWEALTH OF MASS''CHUSETTS
DIVISION OF PROFESSIONAL LICENSURE
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE AS A
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LICENSED JOURNEYMAN.GASFITTER
WILLIAM B HOLMES 9 HUNTERS TRL z
SANDWICH,MA 02563-2701
- N
3942 05/01/2018.. 39315
315
LICENSE NUMBER EXPIRATION DATE SERIAL N.44211