HomeMy WebLinkAboutBLDG-16-006809 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'I cm let7/4l NA DDATE_ Q. Ouo7. r#r# -4,6li�'.,.• 11LC1c.- �04 .& NRIERSNAME L24)r
JOBSITE ADDRESS �G OWNER ADORESS SY/1$ I TEL4OI7-10,2-naFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL v!J
PRINT /
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT®/ PLANS SUBMITTED:YES❑ NO 0
APPLIANCES) FLOORS e®I 1 2 3 4 5 8 7 8 0 10 11 12 14
BONER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
— FURNACE • I .
GENERATOR
GRILLE
INFRARED HEATER
LAE0•RATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM:SPACE HEATER
ROOF TOP UNR _..�_.
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 7 NO 7
I IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TIE 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 112 of the
Massachusetts General Laws,and that my signature on This permit application waives this requirement.
CHECK ONE ONLY OWNER�] AGENT❑ ,
SIGNATURE OF OWNER OR AGENT
1 rerecs cenlry teal al of the details and Inhemat m I have sutlrnNed or entered nailing this appicalr"are:rut and aCWrHe OMladge
and nal al plunming*oat and nstaniWne performed underlie perms Issued VIM application A111 be 11:anoxia _, of the
rdia.ssam..sella Stale Punting Code and''..!'Ia rter 142 acne General Laws
PLUMBER-GASFRTER NAME Kevin Saunders LICENSE#4546M,3860J / -Ey TIIRl-----,�.
MP❑ MGF® JP❑ JGF® LPG!0 CORPORATION®* PARTNERSHIPS I LLC[]*
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
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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