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HomeMy WebLinkAboutBLDG-17-003444 MASSACHUSETTS UNIFO APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK write CITY _ MA DATE_ PERMIT#/ -0-416 19 U JOBSITE ADDRESS_ 1ca S_ _ OWNER'S NAME__I / esdal GOWNERADDRESS MAP e2 3 PARCEL - 3 _TEL '_L FAX— ---- TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS—. 8551 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER • CONVERSION BURNER I COOK STOVE DIRECT VENT HEATER DRYER — I 1 I I I FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST I j UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER • INSURANCE COVERAGE I have a current IiabiIit insurance policy or its substantial equivalent which meets the requirements of MGL.C h.142 YES ® NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY 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 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 accurate 'noMedge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit of the Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME KEVIN SAUNDERS LICENSE#M4546 NATURE J3860 MP❑ MGF® JP 0 JGF© LPG'0 CORPORATION❑X# PARTNERSHIP 0# LLC 0 a COMPANY NAME SEASIDE GAS SERVICE,INC ADDRESS 67 HELMSMAN DR CITY_YARMOUTH PORT STATE MA ZIP 02875 TEL SOB 771 2788 Mo,We,Fr _ FAX __ CELL 508 400 0943 KEVIN __ EMAIL SEASIDEGAS@COMCAST.NET r ROI(:I-I GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 1/— 6 0/( Yes No _ THIS APPLICA11ON SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ---