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HomeMy WebLinkAboutBLDG-18-003187 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r k..„, zl CITY______5lAg..M..____ II Z{o`"�� PERMIT#1- /�tz"4--oa3_7 Pe-i-(-- MA DATE _-11 /� . JOBSITE ADDRESS_35�j b��2�AE/ - OWNER'S NAME 62. L 4- GOWNER ADDRESS MAP PARCEL _ TEL 5--DgAii:12%.L FAX_ I PE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[g•-'"----- PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:Q7----- PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-. &SM 1 2 3 4 5 6 1 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _________ FRYOLATOR FURNACE I I GENERATOR GRI LLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM i SPACE HEATER ROOF TOP UNIT TEST I UNIT HEATER UNVENTED ROOM HEATER WATER HEATER FOTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ] OTHER TYPE INDEMNITY ❑ 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I haee submitted entered regarding thisapplication are true and accurate of nowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit 1 pro n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME KEVIN SAUNDERS LICENSE#M4546 — NATURE J3860 MP❑ MGF® JP❑ JGF© LPGI❑ CORPORATION ❑X # PARTNERSHIP❑# LLC❑# COMPANY NAME SEASIDE GAS SERVICE.INC _ ADDRESS 67 HELMSMAN DR CITYYARMOUTH PORT _ STATE_MA ZIP 3675 —_--_ TEL 508 771 2768 Mo.We, Fr FAX CELL 508 400 0943 KEVIN EMAIL SEASIDEGASQCOMCAST.NET I + SD 4 --- .1° \\ 3 L.Rhi- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: S PERMIT# PLAN REVIEW NOTES