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HomeMy WebLinkAboutBLDG-24-722 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ZZ CITY y��Mo . MA DATE df 'as ati PERMIT 8��� 2�t-? JOBSITE ADDRESS 3? .fcurc A AC OWNER'S NAME COCCA-RO OWNER ADDRESS 2 ati rc LA-PG TEk•g)$gQ 4)6 e• FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ( REPLACEMENT: ❑ PLANS SUBMITTED: YES] NO❑ APPLIANCES 1- FLOORS-I BSIvl 1 ? 3 4 5 6 7 8 s 10 11 2 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN 1—VE �. POOL HEATER / " e • ROOM!SPACE HEATER NOV 25 2t ROOF TOP UNIT TEST ... -Mr UNIT UNIT HEATER 3U�rG UNVENTED ROOM HEATER WATER HEATER �~ OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the • Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME6er otiCelk9krN/,,$ S'ocv,ce LICENSE# c}6>"1 NATURE MP ❑ MGF❑ JP © JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP Li# LLC❑# D,3A COMPANY NAME �zgo�, se&>_ ADDRESS III SPRi L W LA jit CITY . \/,4J1„� STATE 1MA ZIP O')'613 TEL C.5°g)-Y18- fti34 FAX CDC:COD 1 4. 1 431 EMAIL SCtk grr a t yA-hoo.Co ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 'des No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES