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HomeMy WebLinkAboutBLDG-17-002862 a 1 MASSACHUSETTS U IFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V ' ko � le- I CITY____ _ __`-__ MA DATE _ 7�I (12 PERMIT# I,&v/7—a2d`g-4' JOBSITE ADDRESS- - 47 L & k-S OWNER'S NAME LQ "� w qe 0. G OWNER ADDRESS MAP _�� PARCEL_�L'f' _ TEL_ aL'.6 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL D' EDUCATIONAL E RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:ESK---' PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST ,'3 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 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POLICY E 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 El AGENT ❑ 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 of nowledge and that all plumbing work and installations performed under the permit issued for this application wit be in compliance wit I pro • ' n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME KEVIN SAUNDERS LICENSE#M4546 r NATURE J3860 MP❑ MGF® JP❑ JGF© LPGI❑ CORPORATION ❑X # PARTNERSHIP ❑# Lc❑# COMPANY NAME SEASIDE GAS SERVICE.INC ADDRESS 67 HELMSMAN DR CITY YARMOUTH PORT STATE MA ZIP 02675 TEL 508 771 2768 Mo. We. Fr FAX CELL 508 400 0943 KEVIN 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