HomeMy WebLinkAboutG-12-726 ., Cum Ox Apt,ria} G Iz -?2c.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING
'e'-- $ CITY/TOWN: South Yarmouth STATE:MA APPLICATION DATE: 5/21/12
18 Reardon Cr
JOB ADDRESS:
GOCCUPANCY TYPE: COMMERCIALr RESIDENTIAL❑ PLANS SUBMITTED: YES❑ NO❑
NEW ALTERATION!: REPLACEMEM❑ REMOVAL/DEMOLITION❑
r NATURAL& LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT-APPLIANCES-SYSTEMS 1
ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS
AIR ROTATION UNIT J— I FURNACE: ALL TYPES I-1 TEMP HEATING EQUIPMENT I--1
BOILER:ALL TYPES —1 GAS PIPING J f THERMAL OXIDIZER J--1
BOOSTER —. GENERATOR(STATIONARY ENGINE) J TURBINE J—,
BROILER — ILLUMINATING APPLIANCE J-1 UNIT HEATER J-5I
BURNER: ALL TYPES r—I, INCINERATOR I—I WATER HEATER: ALL TYPES J-1
--I. _
CO-GENERATION UNIT
. INDUSTRIAL AIR HANDLER J� EQUIPMENT OVER 12,500MBH I--I
COFFEE ROASTER —J INFRARED HEATER J-I OTHER NOT LISTED? 1-7
COOK APPLIANCE HOUSEHOLD K• ILN I GLORY HOLE I CRUCIBLE J-1 n-1
COOK APPLIANCE COMMERCIAL --I LABORATORY COCKSII (5 heaters, 11--1
DECORATIVE APPLIANCE I M• AKEUP AIR UNIT I gas piping 8 test) I J—�
DIRECT VENT APPLIANCE I MECHANICAL EXHAUST EQUIPMENT
DRYER: ALL TYPES OVEN: ALL TYPES I IJ
FIREPLACE:VENTED I UNVENTED I P• OOL HEATER I II I
O FRYOLATOR I ROOF TOP UNIT I
FUEL CELL I R• OOM HEATER-VENTEDNENTLESS II
PLUMBING/GAS FIFFING FIRM INFORMATION CHECK ONE ONLY
1 NAME: Seaside Gas Service ADDRESS: 67 Helmsman Dr ['Corporation Business#
? ❑Partnership Business#
.. c..\)am Yarmouth Port STATE: MA ZIP: 02675 _ I
V ❑LLC Business#
TEL: 508400-0943 C FAX: 362-3682 EMAIL: seasidegas@comcast.net
❑DBA 1 Unincorporated
tNAME OF LICENSED PLUMBER 1 GAS FITTER:
1(1p INSURANCE COVERAGE
�! I have a current Jiability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy❑ Other type of indemnity 0 Bond ❑
csi
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 0
Signature of Owner or Owner's Agent
OWNER'S NAME: Titan Realty Trust(CC Insulation) I TEL: 508-775-1214 FAX
I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to
the best of my knowledge.I certify that all plumbing work and installations performed under the permit issued,will be in compliance with
all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of th• •neral Laws.
(OFFICE USE ONLY) Type of License: �/
Permit# ❑Plumber QGasfitter et r• —
L—Master ❑✓ Journeyman 'i.na re of Licensed Plumber/Gas Fitter
Inspector RECEIVED — 3860 �
Undiluted LP Installer License Number:
Fee:
AY 2 1 2012 1—Limited LP Installer
i/ at t /0C
B I DING aEPARTME T
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