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HomeMy WebLinkAboutBLDG-17-000270 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ► • CITY E ll /321 MA DATE 7—i ? PERMIT# -t2 /7—OW a�Q JOBSITE ADDRESS 17 -59412W tY/al WI OWNER'S NAME ki-mx-,Z,vdtet,L... CANER ADDRESS 79 f I Z z/g1 TEL 6/7 70 I --<-1/76'FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[ PLANS SUBMITTED: YES❑ NO APPLIANCES 1 FLOORS-. - 2 3 4 S E 7 8 9 10 t1 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR1 FURNACE GENERATOR GRILLE INFRARED HEATER f LABORATORY COCKS MAKEUP AR UNIT _OVEN 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 poicy or its substantial equivalent which meets the requiirements of NIGL Ch.142 YES 17 NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRitATE BOX BELOW LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY L, BOND L NER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142ofthe Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SiGNATU'RE OF OWNER OR AGENT _ ere certify that at of re details are]mrcrrna ar I nave auter¢mtedl or entered regarmrr this ap 4 anor art eruct One accurate e• • and rival at plrrebing work am elEtaltaeorE pert:it ed under the perrnt Issued for This appacatlan M1Il be in complante or - • DTl1! Massacnuse is Stale 31.rrtbrig Ccde and c1aYter 142 of the General Laws PLUMBER-GASFITTER NAME Kevin Saunders LICENSE 4 4546M, 3860J / •i MP❑ MGF E JP❑ JGF® LPG'U CORPORATION® PARTNERSHIP a LLC❑• COMPANY NAME Seaside Gas Service, Inc ADDRESS 67 Helmsman Dr CRY Yarmouth Port STATE MA ZIP 02675 -_L 508 771 2768 FAX v__L 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