HomeMy WebLinkAboutBLDG-17-005161 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PER . RM_.GAS F TT
---
1...".. . 3 PERFORM GAS FITTING WORK
g r? CITY (k) MA DATE 1-6 •-1 PERMIT NAP I7—do5 41
JOBSITE ADDRESS S' Lea-4 GI OWNER'S NAME 1'
GOWNER ADDRESS erg/ Io TEL p.80• 1 'O 3 V3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL C EDUCATIONAL. ❑ RESIDENTIAL y
PRLVT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 111 ' PLANS SUBMITTED: YES 0 NO Q
APPLIANCES 1 FLOORS—. ESIJ 1 2 ' 3 ' 4 5 a 71 S 9 I 10 11 12 13 14
BOILER
BOOSTER —
i ;
CONVERSION BURNER 1___ ___L_
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYC. TOR1
FJRNACE i i
GENERATOR i i i
GRILLE i
INFRARED HEATER { I
i
LABORATORY COCKS
_—
MAKEUP MR UNIT
OVEN ; I
POOL HEATER
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 MGL.Ch.142 YES NO 0
I IF YOU DECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Li 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 j AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certnp that al of the details and Information I have submitted or entered regarding this applcanon are true and accurate - :e.:a of ' owledge
and that al plumbing uoork and hstallattone performed under the permit Issued for this application will be In compliance with r pro .' of the
Massacnuseels Slate Ph rnbing Code and Chapter 142 of the General Laws
PLUMBER-GASFITTER NAME Kevin Saunders LICENSE#4546M,3860J--�i Tll --
MP C MGF EX JP[ JGF;] '_PGI ❑ CORPORATION®* PARTNERSHIP ■ # LLC❑4r
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
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