HomeMy WebLinkAboutbldf-16-002998 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITYCiL MA DATE 11— 1l—it PERMIT# � l�9'Ol%o7
�D � 0 Ewan JOBSITE ADDRESS OWNER'S NAME �M-
y
GOWNER ADDRESS 9Of 131 TEL 3 4'74o FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL "
PRINT
CLEARLY NEW:, RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR j
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/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 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 accur. th= .est of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance •' et ent. . ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Kevin Saunders LICENSE# 4546 IGNATURE
MP❑ MGF® JP❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Seaside Gas Service, Inc ADDRESS 67 Helmsman Dr
CITY Yarmouth Port STATE MA ZIP 02675 TEL 508.771.2768
FAX 904.216.0517 CELL 508.400.0943 EMAIL Permits@seasidegasservice.com
40 — $ c zfit
s
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
R0/7t C ci4f /l/�30/(c Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES