HomeMy WebLinkAboutBLDG-16-006595 _, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY ._ a MA DATE ,9`'6� /� PERMIT# /.406 6 Jr
JOBSITE ADD ESS ' - fi 6 I,,,—OWNER'S NAME natr/1.�,�/'te f 1 -
G OWNER ADDRESS1141 I
I TELL AX 1
! PE OR OCCUPANCY TYPE COMME CIAL EDUCA AL RESIDENTIAL
PRI NT
CLEARLY' NEW: RENOVATION: ' REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES i FLOORS-. as.4,1 1 2 3 4 5 b i 7 8 ? 1:t 11 12 13 14
BOILER 3
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER y
DRYER
FIREPLACE 8
FRYOLATOR
FURNACE I- j _
GENERATOR .I
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT ,._1-_
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT _ ,
TEST
UNIT HEATER ' g v
�—
UNVENTED ROOM HEATER - it I
WATER HEATER i
OTHER
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
UABILITY 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 71
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate t best •f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all e rent • .vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME KEVIN SAUNDERS LICENSE# 546 t . 4ATURE
MP L! MGF JP JGF LPG! CORPORATION i I# PARTNERSHIP LLC - #r
COMPANY NAME: SEASIDE GAS SERVICE INC ADDRESS`67 HELMSMAN DR
,
CITY YARMOUTH PORT STATE MA ZIP 02675 TEL 503 771 2768
FAX 744-994-8459 CELL 508-400-0943 EMAIL SEASIDEGAS@COMCAST.NET
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