HomeMy WebLinkAboutBLDG-17-004641 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
' CITY ekaii R'e-4-- MA DATE 3� 0 PERMIT#p--,oz--/7'"157d/6y/
JOBSITE ADDRESS 6 (- v& OWNER'S NAME g i F2
GOWNER ADDRESS 1 ( I )-- TEL 335=2{049-1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL
PRL''N'T
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES l FLOORS-- j 5SM 12 3 4 5 d 7 8 9 10 11 12 '3 14
BOILER I j
BOOSTER
CONVERSION BURNER I
COOK STOVE
DIRECT VENT HEATER
( DRYER
FIREPLACE
i FRYOLATOR ,
FURNACE I
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS #
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM;SPACE HEATER
ROOF TOP UNIT
I ,.......
TEST
UNIT HEATER a �,.,-,_.�,
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 CIECiaNG THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [x 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 ] AGENT ID
SIGNATURE OF OWNER OR AGENT
I hereby certify thai al Vine derails and InTormatlor I na1'e suber*tted or entered regarctng this appicatlyn are true and accurate ^ • e .=i of . owledge
and tthal at plumDing work and Inetatiattone performed under The perms IEeued for this app l aticn will be In compliance wtth - , -p pro of the
Massachusetts Stale alu nbing Code and Diaper 142 of the General L3wE
PLUMBER-GASFITTER NAME Kevin Saunders LICENSE*4546M,3860J i - - TU,
MP C MGF❑X JP[ JGF] LPG' ❑ CORPORATION®a PARTNERSHIP I * LLC ❑*
COMPANY NAME Seaside Gas Service, Inc ADDRESS 67 Helmsman Dr
CITYYarmouth Port STATE MA ZI° 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
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