HomeMy WebLinkAboutBLDG-17-000880 =..-' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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7 > CITY J MA DATE ��Co PERM � �3� —!/�(9 i�
JOBS yZ /ITE ADDRESS . "" ii W OWNER'S NAME I IQaVI
GOWNER ADDRESS 61"/ 1�fP TEL D/'3 1,--3D L FAXTYPE 6
OR OCCUPANCY TYPE COMMERCIAL C EDUCATIONAL ❑ RESIDENTIAL
PREENT
CIEARLY
NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS* 86LI 1 2 3 4 5 8 7 ' B 9 10 11 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER
a
COOK STOVE
DIRECT VENT HEATER
DRYER r
FIREPLACE
_FRYOLATOR
...... FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM, SPACE HEATER
ROOF TOP UNIT l I
TEST
I i I l
UNIT HEATER
UNVENTED ROOM HEATER } I.
WATER HEATER
OTHER
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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 [ NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELCH
LIABILITY INSURANCE POLICY (x OTHER TYPE INDEMNITY L BOND C
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 signalrrre on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE OF OWNER OR AGENT
I hereon'ceruty that at of the details and Irrforma ion I nave suteMled or entered regarding this application are true aria accurate + . e
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and than at plunsding etE1 and v sIauaItopE performed under the permit Issuce ror 11nt6 animation vim be CornpIla ee rmn of me
Massacnetls Stale�II,rnbn Ch
g Code and anter 142 of the General Laves 3
PLUMBER-GASFTTTER NAME Kevin Saunders LICENSE*4546M, 3860J ' -- 4T'-TURL*-------. _ I
MP C MGF a JP L JGF❑X LPG!❑ CORPORATION®* PARTNERSHIP I LLC Os
COMPANY NAME Seaside Gas Service, Inc ADDRESS 67 Helmsman Dr
CITY Yarmouth Port STATE MA ZIP 02675 TEL 508 771 2768
FAX CELL 508 400 0943 EMAIL PERMITS@seasidegasservice.com
(..41—C)
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $_ PERMIT#
PLAN REVIEW NOTES