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HomeMy WebLinkAboutBLDG-17-005387 • -' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY � ' 11 �MA DATE —!�P 1 7 $ =� ^ ` JOBSITE ADDRESS 3S+3 / G•�-(*CO?iot OWNER'S NAME GOWNER ADDRESS St (bZ TEL 1I, 3t1.6• FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL PRINT - CLEARI.4' NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLIANCES L FLOORS— I 1 23 45 3 7 8 8 10 11 12 '3 14 BOILER 0" BOOSTER CONVERSION BURNER COOK STOVE D NRECT VENT HEATER DRYER FIREPLACE FRY►OLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP MR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP LIMIT TEST I 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 IIGL.Ch.142 YES [ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW L[ABILITY INSURANCE POLICY (x OTHER TYPE INDEMNITY L_ BOND ❑ OWNERS 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 L SIGNATURE OF OkMNER OR AGENT i rerer:1y cerury teat at ante details and Information I nave tub/TAM or entered regarding this appicatlon are true and accurate e• of aaleOge • and Coat al plumbing work and mstaltauons performed under re perms Issued for this appitauon wut be In compMance wrm e r pro of the Maesacnuseas Slate Plumbing Cade and Cnapter 142 of the General Laws PLUMBER-GASFITTER NAME Kevin Saunders LICENSE*4546M, 3860J- - -- TURD--- MP❑ MGF® JP❑ JGF® LPG!❑ CORPORATION ®* PARTNERSHIP * LLC❑ COMPANY NAME Seaside Gas Service, Inc ADDRESS 67 Helmsman Dr CTY Yarmouth Port STATE MA ZIP 02675 TEL 508 771 2768 FAX CELL 508 400 0943 EMAIL PERMITS©seasidegasservice.com 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