HomeMy WebLinkAboutBLDG-25-467 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK U
— r CITY: / 'WI QZt MA. DATE: / /3`e PERMIT# L/)o ZS ll'2
JOBSITE ADDRESS:3 t Y'C'�.%f' 1h}I('vi OWNER'S
e" NAME: RQ wr
G OWNER ADDRESS: I a �, 4- c 4sal TEL7- 7�I1?/S21?FAX: /
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[—�'
PRINT
CLEARLY NEW:❑ RENOVATION:III REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
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
lj INFRARED HEATER
W LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
J ROOF TOP UNIT V/
TEST
Z UNIT HEATER
,U UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES❑NO 0
If you have checked YF$,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 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 OF OWNE 'R AGENT
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 end that all plumbing work and installations performed under the permit issued fords application will be In to ce all Pertinent
provision of the Massachusetts State PlumbingCode and Chapter 142 of the General Laws.
PLUMBERIGASFITTER NAME: /v4USP' :Track C.Yn.t LICENSE#166?? GNATURE
COMPANY NAME:M ( 2a- ADDRESS: 30)
CITY: 4-Y t- r4'1MOn STATE:``A/1 A- ZIP: O ? FAX:
TEL: S//Z i CELL:-Vq.2-5//Z b ZEMAIL: 11' -)1r?c_(g 774-E 6-4'40r
MASTER JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP❑# LLC([I# 1-
c rn,9"c, AD7XLess'.h ra 1 Y?0-6- -nia RECEIVEDI
SEP 3 2025
BUILDING DEPARTMInNT
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
i1
I ram.. OCCUPATIONAL LICENSURE
BOARD OF
`t-PLUMBERS AND GASFITTERS
SUES THE FOLLOWING LICENSE
MASTER PLUMBER a
iu
is
MOSES JOACHIM 10
301 BUCK ISLAND RD
W YARMOUTH,.MA 02673 ;
16677 05/01/202f 606398 I .
ICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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