BLDG-19-001409 yr•.,_ .;. 4'30•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
—ir _ty ,
;S. �Q CITY Yarmouth Port MA DATE 08/21/18 PERMIT# ,n17'/7�y'�d/907
JOBSITE ADDRESS 14 Strawberry Lane OWNER'S NAME Joan Perera
GOWNER ADDRESS 13 Birchwood Lane,Lincoln MA 01773 TEL 508-362-3971 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL El
PRINT '
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:D PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 [ F r r r� r ft Tr r dr r
BOOSTER
_ ii ( I.
CONVERSION BURNER I it it �I
COOK STOVE I , ( �( li IF
DIRECT VENT HEATER I I I
DRYER I I _ I l
FIREPLACE r I
FRYOLATOR I i
FURNACE f
GENERATOR i
ll
GRILLE I i I I
INFRARED HEATER iL A OR TOR UCOIT 1111
LABORATORY COCKS i
J � i
il
OVEN U l I _
POOL HEATER I
ROOM/SPACE HEATER II ;,
ROOF TOP UNIT
TEST - --=1— V__ H
UNIT HEATER �l I , i
UNVENTED ROOM HEATER I I i i I
WATER HEATER 1 11111
I {I , lOTHER I U u I Il fU IIi it -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW •
LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY D BOND ❑
OWNER'S INSURANCE WAIVER:lam 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 IN 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 ands: curate the .e • my kno dge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliao 'th all ertin t •ro '•n oft -
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -
PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 1f NATURE
MPD MGF❑ JP ED JGF❑ LPGI❑ CORPORATIONQ# 3698C PARTNERSHIP❑# LLC❑#
COMPANY NAME: South Shore Heating&Cooling,Inc. ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL
Mir
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 F
- - I
1