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110.4 ` . r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
5 Slim 0pll� � CITY CU- !l _., _f1 MA DATE . IO I LfI I✓ PERMIT#_G/y- /lc
JOBSITEADDRESSI.-I �,� 6. �/�/� Y— OWNER'S NAME { / ir-(S�""'
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OWNER ADDRESS --- -` 1 TELI1_I (: la51 FAXL________. i
TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL F- RESIDENTIAL[
PRINT
CLEARLY NEW:-RENOVATION:[] REPLACEMENT: _l PLANS SUBMITTED: YES[T] NO[]
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER — — — ---
BOOSTER 1 I I
CONVERSION BURNER i J 11111111111 NM;- -- _.
COOK STOVE ��I� � , / /� _ __.m.
FRYER DIRECT VENT HEATER - ��® /t// _
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FIREPLACE --
FRYOLATOR — r,
FURNACE I
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MAKEUP4.
GRILLE
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AIR
POOL HEATER
ROOM I SPACE HEATER MN _ _ _ cil-® -
ROOF TOP UNIT
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[n UNIT HEATER SUM' 111111.111 /6
UNVENTED ROOM HEATER ME'i M'
WATER HEATER — —
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$4R`E-FitJ=E-1 — -
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OCT. t _
2013 _
INSURANCE - - _
COVERAGE
h• e • -• :;,:,4...,•';-i to.licy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES R1 NO I
BUILDIN •Jai,
I IF OA • • •. 1•1 --' - TE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 121 OTHER TYPE INDEMNITY Li BOND ,j
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 D AGENT [,3
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 and ccurate to - best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In complianc: wit /"t - • •i of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,
_sagPLUMBER-GASFITTER NAME I Joseph Ventresca I LICENSE# 15742._I SIGNATURE
MP[+] MGF['_] P in JGF[] LPGI[ CORPORATION FP 3255 fl PA" • RSHIP[1#j1 LLC E#n
COMPANY NAME. South Shore Heating and Cooling I ADDRESSIF Whites Path_ ,.
CITY [South Yarmouth 1� STATE MA 1ZIP[02664, ITELLS08-398-6901
FAX508 760-2681 a I 3605277 CELL508- - EMAIL ioe@southshoreheatingcooling.com
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