HomeMy WebLinkAboutBLDG-16-004927 MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSTE ADD SSE Sip ,; U PlI. 1 I OWNER'S NAME[ ^ /1 1t%& ]
G _ OWNER ADDRESS l►t, ' ININNINNI a 1 raj 7 )Oszj_/$3 IFFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL! RESIDENTIALT"
PRINT
CLEARLY NEW:[ RENOVATION:p REPLACEMENT:z PLANS SUBMITTED: YESfl NO0,
APPLIANCES 1 FLOORS- esti ' 1 2 3 4 5 8 7 8 1 9 1 1011 12 13 14
BOILER C li d c i�
6OOSTERONVERS e: .>aer aai.aaya-nain a�–ten a�r.e�i ar..
CONVERSION BURNER u /I:, e ;
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COOK STOVE ' or
DIRECT VENT HEATER I i 4 t. r
DRYER I I i I
Fl REPLACE —— _. '�' Th._.__ y:s._._ .a"
FRYOLATOR
FURNACE yi — —1I i I i
GENERATOR
GRILLE l i �i i — ! p
INFRARED HEATER ~! – I t '
LABORATORY COCKS i
MAKEUP AIR UNIT i I t I r
WON i I _ i I — ` 9 _i — 1
ROOLHEATER i i = ;
ROOM ISPACE HEATER
ROOF TOP UNIT 4 1 t 1' l
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UNIT T HEATER -TEST • oras C.......1 �.-i,�l tnar>r„nymmIt-.ar. -` — - -- =
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UNVENTEDROOM HEATER ~��
WATER HEATER LM 1 , . t ®+ ...ala_.., E .
OTHER 1 f� !____ b-- _ _._ '-.�_ _r'' i
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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, NO El
I F YOU DECKED YES,PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POIJCY Q 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 permit application waives this requirement.
_ CHECK ONE ONLY: OWNER 0 AGENT L'7,
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the detals and infonnatien I have submitted or entered regarding this application we true and accurate ,• . ; -� :,.a
and that al plumbing work and installations performed under the pemrit issued for this application Ml be In compliance with the _
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTERNAME 1KevinSaunders LICENSE#4546 • TTURE
MP 0 MGF%} JP JGFu LPGI9 CORPORATION 0#t______I PARTNERSHIP #J i,LLC q#
CCh1PANY NAMElSeaside Gas Service,Inc IADDRESS{fi7 Helmsman Dr '
CITY j1'armouth Pat ( STATE MA (ZIP 02675 ' TEL 508/712768
FAX I I CELL 508.400.0943 (EMAIL PERMITS@seaskiegasservice.com
POOCH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES • j
Yes No
• - ' THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT II
PLAN REVIEW NOTES