HomeMy WebLinkAboutBLDP-19-003077 a_ \l0 '00
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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74091 CITY )/yrMcotG( MA DATE C1 Z PERMIT# �- t..30a7
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JOBSITE ADDRESS / errit-G10a'®®S Ga. (OWNER'S NAME Ar T
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GOWNER ADDRESS t//}dYki 0pcur 1t— JTEfl ¢- 7/SI (FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:DI RENOVATION:DI REPLACEMENT: PLANS SUBMITTED: YES NOD
APPLIANCES 7 FLOORS-0 BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BOILER 1 r 9
BOOSTER {
CONVERSION BURNER
COOK STOVE , i
DIRECT VENT HEATER I
DRYER
FIREPLACE I
u I
FRYOLATOR f __
S0, FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS I_ I
MAKEUP AIR UNIT , U _
OVEN i I 1 1. ,
POOL HEATER I !
ROOM/SPACE HEATER
ROOF TOP UNIT _ {L
TEST l 1
UNIT HEATER I II {
UNVENTED ROOM HEATER , _, I
10 WATER HEATER �I
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 Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ 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 .• acc ,=te t. he • o my n•wledge
and that all plumbing work and Installations performed under the permit issued for this application will be in comp J•ce wi all P i nt•ro ' ion oft -
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE# 11601 SIGN a TURE
MP 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 3698C PARTNERSHIP❑• LLC• ❑#—
COMPANY NAME: South Shore Heating&Cooling, 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
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ et/i/fti l '4c. y� ��
FEE: $ PERMIT# ` J [,[a I/1/(`—
PLAN REVIEW NOTES f� .
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