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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I south 12M2uth MA DATE 11-9-2016 —:] PERMIT # 8$
JOBSITE ADDRESSI 33 hatch rd OWNER'S NAME I curt baker
GOWNERADDRESS I TE 774-836-7975 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ® REPLACEMENT: ® 6 PLANS SUBMITTED: YES[ NOF_]
APPLIANCES 7 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
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [j NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY F] 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 ® AGENT El
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 an curat he best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compf ' e 't II Pertin t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I Keith J. Farnham LICENSE # 11601 SIGNATURE
MP [D MGF ® JP ® JGF ® LPG[ ® CORPORATION 0# 3698C PARTNERSHIP®# LLC ®#
COMPANY NAME: South Shore Heatin & Coolin ,Inc ADDRESS 157 White's Path
CITY South Yarmouth STATE [:MAj ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL
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