Loading...
HomeMy WebLinkAboutG-18-3653 •� MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK US LQ'CITY_ L Q, _ ;1--- MA DATE _tft-/17 PERMIT#ike1/2% %%63 / q�� /�l''nn,� JOBSITE ADDRESS_ QL'i� s aQ_ --- OWNER'S NAME_ C,11 2 IA GOWNER ADDRESS MAP PARCEL TEL DtQ•S-T75FAX_ TYPE OR • OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑ APPLIANCES 1 FLOORS-4 69,1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CCNVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR • FURNACE / 1 GENERATOR 'y1 VI GRILLE I/ INFRARED HEATER LABORATORY COCKS / r MAKEUP AR UNIT V OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER 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 F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY ❑ 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. _ CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and nfamation I have submitted a entered regarding this application are true and accurate • •: •:. of 'nowledge and that all plumbing work and installations performed under the permit issued for this application coil be in compliance wi• •. .. pro : • of the Massachusetts State Plumbing Code and Chapter 142 of the General laws. PLUMBER-GASFITTER NAME KEVIN SAUNDERS LICENSE#M4546 . • NATURE J3860 MP❑ MGF® JP❑ JGF® LPGI❑ CORPORATION 0# PARTNERSHIP❑# LLC❑# Comm,NAME_SEASIDE GAS SERVICE,INC _ ADDRESS 67 HELMSMAN DR CITY YARMOUTH PORT _ STATE MA ZIP 02615 TEL 508 771 2768 Mo,We, Fr FAX CELL 508 400 0943 KEVIN EMAIL SEASIDEGAS©COMCAST.NET $ 4- 3bdI 7 /Z z.-2(A ROUGH GAS INSPECTION NOTES THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE: S PERMITS PLAN REVIEW NOTES