HomeMy WebLinkAboutBLDG-24-189 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
����M" ,�-�.-(- MA DATE ) /`y PERMIT# VLDG---h- 1'9
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JOBSITUE ADDRESS 5 7� MA-• p OWNER'S NAME
GOWNER ADDRESS 7j �'} 2-4 TEL 7?LI 7 1 L903S FAX
TYPE OOCCUPANCY TYPE COMMERCIAL EDUCATIONAL
� ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT
PLANS SUBMITTED:YES 0 NO4----'
APPLIANCES-1 FLOORS BSM I 2 3 4 5 6 7 8 9 10 11 12 13 12
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER _
DRYER -
FIREPLACE
FRYOLATOR
FURNACE --
GENERATOR -
GRILLE
INFRARED HEATER -
LABORATORY COCKS _
MAKEUP AIR UNIT - _ _
OVEN
POOL HEATER
ROOM/SPACE HEATER -~1
ROOF TOP UNIT - - FIE C E V E 9._
TEST .
UNIT HEATER -
UNVENTED ROOM HEATER R 2024
WATER HEATER
OTHER / B JDIN �CNT
l Apr � efts pipe _ IL
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY j OTHER TYPE INDEMNITY 0 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 Laws,and that my signature on this pennIt application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
4+ 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 06my
and that all plumbing work and installations performed under the permt Issued for this application will be in com Ilan with II Pe nt provision
' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME e n /l' LICENSE#1 1-(e L SIGNATURE
MP K MGF❑ JP❑ JGF 0 LPGI❑ CORPORATION❑4 PARTNERSHIP# ILC❑#
COMPANY NAME ADDRESS /00kn \ (--
P
CITY_ PCvo t.Vg( STATE " ) ZIP f) `--J TEL
FAX CELL �S7d(/D/�� EMAIL f ff a^7 1PN�!'/1&•CO-1--r-1
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
•
•
•
OMMON LTH OF .,;,, , CHUS TT _
EA
DIVISION OF OCCUPATIONAL LICENSURE
. END OF
F, . ' PLUMBERS AND GASFITTERS ---
. ISSUES THE FOLLOWING LICENSE
CC
MASTER PLUMBER
z �
FORREST A FERRILL
V(ul
10 ORCHARD VVAY co
SANDWICH, MA 02563 2555
• P
•
9964 tI f01/2024 250286
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER ' f
•
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