HomeMy WebLinkAboutBLDG-17-003991 _z MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK °
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! . CITY S'�' ;,�mO.)` - MA DATE 1 W 1 ) PERMIT# /� /�C'°"/7`O®•4r
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JOBSITE ADDRESS 109 Tom ' 144" OWNER'S NAME t4Je...
GOWNER ADDRESS 100 - 14k ' TEL )7(4 g7-ifigg- FAX
TYPE OR PRLti"T OCCUPANCY TYPE COMMERCIAL C EDUCATIONAL ❑ RESiDENTIAL
CLELRLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [" PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES 1. FLOORS-. 155t1 1 2 3 4 d d 7 8 g 10 '1 12 '3 ' 14
BOILER
BOOSTER
CONVERSION BURNER
' COOK STOVE
DIRECT VENT HEATER
•
i DRYER
FIREPLACE
; FRYOLATOR
FURNACE ( . I e x�
. GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS r
MAKEUP MR UNIT j
OVEN °
POOL HEATER
ROOM;SPACE HEATER
.
ROOF TOP UN IT
TEST
` } i l , 1
UNIT HEATER °
UNVENTED ROOM HEATER I
WATER HEATER I r..
OTHER
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INSURANCE COVERAGE
I have a current liability insurance poNcy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES 7 NO I.]
I IF YOU DECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPWATE 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 nereby cermp that al.of the details and Inrorma for I have subrnRted or entered regardng this application are true and accurate •:a .: al owiedge
and Mal al plumbing wont am Installations performed under Inc permn Issued for this application will be In compliance with - . _r pro .. .• ai the
Massachusetts Slate alunbing Code and Chapter 142 of the General Law'
PLUMBER-GASFITTER NAME Kevin Saunders LICENSE*4546M, 3860J---i TU.R. -.
MP C MGF a JP C JGF A LPG' ❑ CORPORATION[ * PARTNERSHIP ■ # LLC 0
COMPANY NAME Seaside Gas Service, Inc ADDRESS 67 Helmsman Dr
C 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