HomeMy WebLinkAboutBLDG-18-002230 1. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
. rf CITY S_ �'` MA DATE it "3-17 PERMIT# 1 Cc%-�30
,..../
JOBSITE ADDRESS 1 1-1 v P / T ��G �� OWNER'S NAMEFF
GOWNER ADDRESS TEL/34,1J31.6 p O FAX
TYPE O$ OCCUPANCY TYPE COA4MERCIAL❑ EDUCAT NAL ❑ RESIDENTIAL 9.c1'
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: , PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-, 1 W1 1 2 3 ' 4 5 ` B 7 . 8 2 10 11 12 13 14
BOILER 1 1
BOOSTER '
CONVERSION BURNER
COOK STOVE
DNTECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER !
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
FOOL HEATER
ROOM;SPACE HEATER
ROOF TOP UNIT
TEST }
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance pokey or its substantial equivalent which meets the requirements of IiGL.Ch.142 YES ® NO
I IF YOU CI ECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CFCCIWIG THE APPROPINATE BOX BELOW
LIABILITY INSURANCE POLICY (i OTHER TYPE INDEMNITY L 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 J AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify trial al of the details ardillyi manor I nave sutenillen or entered regarding this appilcatlon are true ana accurate • a :.,: of owtedge
and that at plurnGing worK and r staltabore performed under the permn Issued for we appacatton¶MII be In compliance Meer - .• . , prov. of the
Massactluselts Stale PIi•rnbing Code and Chapter 142 of the General Laws. +
PLUMBER-GASFITTER NAME Kevin Saunders LICENSE#4546M, 3860J TUR ._
C. __ .__�
MP E MGF[ JP E JGF E LPG! ❑ CORPORATION®# PARTNERSHIP II# LLC❑#
COMPANY NAME Seaside Gas Service, Inc ADDRESS 67 Helmsman Dr
CITY STATE Port STATE MA ZIP 02675 TEL 508 771 2768
FAX CELL 508 400 0943 EMAIL PERMITS@seasidegasservice.com
N
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES