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HomeMy WebLinkAboutBLDG-19-001878 So ` otz) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -'o'er '112lit- CITY /A4`N}0VOL MA DATE as. QQ 7. 07 PERMIT# ti /P—OC/'Z'' JOBSITE ADDRESS V C C W E'R y, fi NAME p-- is GOWNER ADDRESS Wert-041t-041 I TEI.5OR-72S`2/4.3PAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL a PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Dvar PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 7 FLOORS—. BSM 1 2 3 4 5 6 7 - 8 9 10 11 12 13 14 BOILER I r BOOSTER Ie CONVERSION BURNER ; 11 1, I I I I I ( COOKSTOVE01--111 DIRECT VENT HEATER i I DRYER FIREPLACE l I FRYOLATOR $o FURNACEORR GENERATOR GRILLE INFRARED HEATER ,I LABORATORY COCKS MAKEUP AIR UNIT OVEN Id POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT li i TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER j OTHER 11!" INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ 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 ❑ 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 a d acc ate o t . .. . .. knowledge . and that all plumbing work and installations performed under the permit issued for this application will be in cornce wi all •- in: t, ovisio• of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��►\ PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 SIGNATURE MP Q MGF❑ JP❑ JGF❑ LPG❑ CORPORATION Q# 3698C PARTNERSHIP❑# LLC❑# COMPANY NAME: South Shore Heating&Cooling,Inc ADDRESS 57 White's Path CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901 FAX 508-760-2681 CELL EMAIL ROUGH GAS INSPECTION NOTES ' THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No a THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# PLAN REVIEW NOTES D ' '