HomeMy WebLinkAboutBLDG-15-003647 1
.t5 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •
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mt i CITY Yarmouth Port MA DATE MSDZ! PERMIT#�J=nb'/h=OQi( i'•
JOBSITE ADDRESS 37 Church St OWNER'S NAME Don Boume '---
GOWNER ADDRESS same-PID 15357 TEL 508-375-0937 IFAX _
TYPE OR OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW: 1 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i — _
BOOSTER
CONVERSION BURNER J I
COOK STOVE
DIRECT VENT HEATER J I
DRYER t J
FIREPLACE
FRYOLATOR I1
FURNACE
GENERATOR i...1.1
GRILLE J t
INFRARED HEATER 1 L
LABORATORY COCKS J
MAKEUP AIR UNIT J I f
OVEN J 1 1 I
POOL HEATER J 'I
ROOM I SPACE HEATER
ROOF TOP UNITE
TEST 1 II
UNIT _• ER {j 1
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0TH R QG�9 11 f
JAN 00 201 J
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boi�uiI t - _ INSURANCE COVERAGE,
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I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a 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: 0 ' ER ❑ AGENT 0
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 a • ra - e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compile•ce , th inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME KEVIN SAUNDERS LICENSE# 4546 SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# 1111111111111111111 PARTNERSHI t 0# _ I LLC(DC
COMPANY NAME:SEASIDE GAS SERVICE,INC ADDRESS 67 HELMSMAN DR
CITY YARMOUTH PORT STATE MA ZIP 02675 f TEL 508-771-2768
FAX __ ,._ CELL 508-400-0943 EMAIL PERMITS@SEASIDEGASSERVICE.COM �
IS N'
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p ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
o� Oar elf //g/t/ Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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