HomeMy WebLinkAboutBLDG-23-6572 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
zj€ ,6w CITY MA DATE 6 / PERMIT# 6 -23 - Z_
JOBSITE A DRESS /Z �� d- �vL OWI ER'S NAME c--
OWNER ADDRESS S o T s 7 t Q —2 (
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY
NEV,AL RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BSIvi 1 2 3 4 5 6 7 5 9 10 11 12 13 14
BOILER
BOOSTER j
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER '
FIREPLACE
FRYOLATOR
FURNACE `*041
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER R E E
ROOF TOP UNIT
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UNIT HEATER I ��LJ
UNVENTED ROOM HEATER -
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WATER HEATER R
OTHER Y- --
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES 0 ❑
I IF YOU CHECKED YES,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 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP X. MGF❑ JPXf JGF❑ LPGI ❑ CORPORATION❑ ' PARTNERSHIP[]tt LLC❑#L
COMPANY NAME ike ( 74W/ 1 �( ' D .E 2 e
CITY W el C STATE nZIP 25 3 g TEL E5O
S) Z.-] �"'74'
FAX CELL EMAIL o cJ 7 3 4 P
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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
Fold,Then Detach Along All Perforations
•DAM. WEALTH OF MA
DIVISION OF OCCUPATIONAL LICENSURE
BOARD of
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
JOURNEYMAN PLUMBER Uf
ROSS A DONi\GHY
205 BARKER RA >.'
E WAREHAM,MA 02538:1286
31725 05/01/2024 235432
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER