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HomeMy WebLinkAboutG-14-287 ir cu1t,0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1.,, �.1t1_c CITY [y._ .. . ._.._. .{, .._ . _...__/- Witsiat 'L._._,,._._ ..,_.. MA DATE i 9li��is PERMIT# b/ 2�c / JOBSITE ADDRESS! [, fl k"� G Rd. OWNER'S NAME r, 7 — _ G OWNER ADDRESS j TEI Sa =3; a-�T37-,FAX[ 15 INT POR OCCUPANCY TYPE COMMERCIALS I EDUCATIONAL[ RESIDENTIAL CLEARLY NEW:( i RENOVATION:[) REPLACEMENT: I [KPLANS SUBMITTED: YES F. NOr APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 6° BOILER BOOSTER — _'— — — - — — CONVERSION BURNER COOK STOVE DIRECT VENT HEATER — — — — -- — — — - DRYER FIREPLACE FRYOLATOR GENERATOR GRILLE - INFRARED HEATER 1 • LABORATORY — POOL HEATER �R. ®® ®MAKEUP AIR UNIT Ill ROOM/SPACE HEATER IIII ���"ffill�_ ROOF TOP UNIT TEST UNIT HEATER „'.�_. SUr •rh 1J: 7f UN VENTED ROOM HEATER to WATER HEATER OTHER I INSURANCE COVERAGE I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES It''NO I .. (IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY If OTHER TYPE INDEMNITY C BOND 1:1 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 [I AGENT I' I 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 t• best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In compliant- With- '--. of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /- 0r Alr` PLUMBER-GASFITTER NAME[Joseph Ventresca`__ — J— 'LICENSE#,15� 742 SIGNATURE MP EI MGF r—, JP f; JGF[I LPGI FI CORPORATION EJ#3255 ` 'P" � 'SNIP I'#' , LLC i-`#j COMPANY NAME:1 South Shore Heating and Cooling I ADDRESS 57 Whites Path s CITY rSouthYarmouth ; STATE M ZIPI,02664 ITEL I 508-398-6901 [.5.9_82760-2681_=z I r�- I I FAX i CELL 508 360-5277 EMAIL Joe@southshoreheatingcooling.com G1' 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 e r •