HomeMy WebLinkAboutBLDG-17-006651 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
Nifirri CITY 4 �`ttThlrs 7- MA DATE 6- PERMIT Or "17-0066 5 /
JOBSITE ADDRESS t'L 2y� OWNER'S NAME 14 0"1 Ge—S
OWNER ADDRESS / (3 TEL 3`"l S t ro act FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
APPLIANCES 2 FLOORS— ES&I 1 2 ' 3 1 4 5 ; 8 7 8 g i 110 f 1 12 13 14
BOILER I
I °
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR I
FURNACE
GENERATOR £
GRILLE
I f ,
INFRARED HEATER
LABORATORY CDC KS I
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MAKEUP AIR UNIT
OVEN
POOL HEATER I
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 MU.Ch.142 YES [3 MO 0
I IF YOU CHECKED YES.PLEASE INDICATE TIE TYPE OF COVERAGE BY CHECKING TIE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LX. OTHER TYPE INDEMNITY L: BONI) D
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 Cereby cerUty that at of the details and Information I have subrnaled or entered regarding tdla applcalion are true and accurate a of Wedge
and that al punting work and Instaltattont3 pertorrned under the permit Issued for this appacafon MI be In compliance with a pro of tree
Maraactlusetls State Plurnbing Code and Camper 142 of the General LaWr6.
PLUMBER-GASFITTER NAME Kevin Saunders LICENSE#4546M, 3860J TUR
MP C MGF a JP C JGF( LPGI❑ CORPORATION Ea* PARTNERSHIP # 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
Af [ ��
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