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HomeMy WebLinkAboutBLDG-24-298 *- MRSSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK$p = = CITY PJ ' YQ RJR O\-3�v\ 2 9-MA DAT �> � PERMIT k L/ -r',.�t�/-�c� JOBSITEADDRESS 3 wi tide mere qD OIMVER'SN.AME 1 G OWNER ADDRESS TEL TYPE OR FAX PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL©------ CLEARLY NEW:L2K RENOVATION:❑ REPLACEMENT:0 PLAN,.SUBMITTED:YES 0 NO❑ OP IANCES 1 FLOORS-. 6 7 8 9 10 11 BEM 1 2 3 4 512 13 j4 ILE BOOSTER CONVERSION BURNER, COOK STOVE I DIRECT VENT HEATER - DRYER FIREPLACE F _ FRYOLATOR FURNACE ATl t L GENERATOR M GRILLE INFRARED HEATER - . _ LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST _ ETE . " _B UNIT HEATER UNVENTED ROOM HEATER WATER HEATER —�— MAY-z-4-2 y OTHER L r LUIIN Utl-a l't IlO7T T - INSURANCE I have a current liability insurance policy or its substantial equivalent COVERAGE nwhichh meets t the requirements of MGL.Ch.142 YES a7NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY 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 J SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El AGENT 0 tb I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac rate o the s f and that all plumbing work and installations performed under the permit issued for this application will be in comp ail erti y kn edge �) Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p ° • PLUMBER-GASFITTE NAME LICENSE#38yZ SIGNATURE MP❑ MGF JP❑O JGF 0 LLPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑# 1"COMPANY NAME INRkS t``` bke SeRNJ tC2 ADDRESS (I CAA lje1`ry RO CITY G k-RA,3 e� STATE M A ZIP G .2 6 3 f 1 TEL FAX CELL77`{- 2110- H I I EMAIL �P, nv�'8 a3 ovhcasT.tie� ROUGH GAS IP' 'IOPd �(43TES THIS PAGE FOR INSPECI OR USE ONLY FINAL INSPECTION NOTES fSPE€:.'i Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • ••• _ ,-:-..IV-:,::.;:ii•:::iCOMMONWEALTH OF MASSACHUSETTS , 9 • • • Oa A • ..•:• ...BOARD:O.: PLUMBERS AND GASFITTERS N . ::•:. -1•1: ISSUES THE.,•FOLLOWING LICENSE GASF1LTT.ER MARK D WATSON " •14, 81•:.CAPTAIN PERRY RD BREWSTEft MA 0263172559 N-.u) • :J- 0 • •:3841 H.' 584090 LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER • • . . • : •,- • • • • • • .. • •