HomeMy WebLinkAboutBLDG-17-001515 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'crag iG CITYSouth Yarmouth IMA DATE'.09123116 f PERMIT# *-41/7-17-*coin(
JOBSITE ADDRESS 180 South Street !OWNER'S NAME Betsy Kamborian
G OWNER ADDRESS 180 South Street -
TEII 7818833133 (FAX r-----
TYPE OR OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL LI RESIDENTIAL[]
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER ; — ___ —1 — I -- - -- -- - - - - -- - - - -
CONVERSION BURNER
COOK STOVE -1,_
DIRECT VENT HEATER
DRYER
FIREPLACE
� 1 1 I ( F � I 1 f 1 I
FRYOLATOR ; •
FURNACE ! 1 -!
GENERATOR
GRILLE
INFRARED HEATER I
LABORATORY COCKS _l
MAKEUP AIR UNIT 1
OVEN
I { 1 I l s 1 I
POOL HEATER ) .....__ 1
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST ____ -1-! - _I - v-! - _I t I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER t I
OTHER) 4 ! 1 ! 1
I
l ! I ! ! 1 11 1 1 r
I 1 ' '11.101.111 NIMPIAMINIIIIIMMINIIII _ l
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑+ OTHER TYPE INDEMNITY [] BOND 0
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: 4 'E: jJ AGENT U
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 ,.,,w1011.1:>,-- e •the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In comp/2, . Pert :nt provisi., • 1 -
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Phillip Durfee LICENSE# 13774 f ' ,t ' .TURE
MP[ MGF❑ JP❑ JGF(] LPG!Q CORPORATION[]# PARTNERSHIP Q# I LLC 0#:3152
COMPANY NAME:I Durtee Plumbing&Heating LLC (ADDRESS 2A Huntington Ave.
CITY South Yarmouth STATE 5MA1 ZIP 02664 (TEL L508-619=3078 a " '1/ C' I
FAX 508-258-0592 CELLI 508.801.8004 EMAILI phil@durfeeplumbing.com;joy@durfeeplumbing.com F I t, l
l]UI SEP 9 7 2111•F I /�
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