HomeMy WebLinkAboutBLDG-17-005361 a
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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j, . • CITY VJ` -1/1 MA DATE ______÷_bd)___ PE IT# rin6-17-"CO 3 1�p
JOBSITE ADDRESS Cx-4C144 j 1 )ILL OWNER'S NAME
GOWNER ADDRESS c - TEL3aI. M.GI18S FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 1 FLOORS-. 1 MI 1 2 3 ' 4 5 8 7 8 8 i '0 ! 11 12 13 , 14
BOILER
,
BOOSTER
CONVERSION BURNER
COOK STOVE '
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
1
GRILLE ,
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN + i
POOL HEATER M `i
ROOM SPACE HEATER +
ROOF TOP UNIT
i
TESTi
UNIT HEATER 1 _—
UNVENTED ROOM HEATER
WATER HEATER
_OTHER i
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [3 110 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CIECIONG THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Lx; OTHER TYPE INDEMNITY L BOND L
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 11
SIGNATURE OF OWNER OR AGENT
I Irereby certify that at of the details and Information I nave sutrnNed or entered regarcIng this applcanon are true and accurate •e',-'of owiedge
and trial al plumbing work and Installations performed under me perrnn Issued for this art ation wit be In compllanee Bann -. :e.Y pro of me
Massachusetts Stale Plu nbng Code and Cnapter 142 of the General Laws. -
PLUMBER-GASFITTER NAME Kevin Saunders LICENSE#4546M, 3860J i"..- -- 4gry.,TU,
MP[ MGF[ JP❑ JGF!X] LPGI❑ CORPORATION®# PARTNERSHIP # LLC Q
COMPANY NAME Seaside Gas Service, Inc ADDRESS 67 Helmsman Dr
C,Tr Yarmouth Port STATE MA ZIP 02675 TEL 508 771 2768
FAX CELL 508 400 0943 EMAIL PERMITS@seasidegasservice.com
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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