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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT-TO PERFORM GAS FITTING WORK
VWs CITY I Af�n�t�714 q--- • 1 MA DATE 1_191.2302.___I PERMIT# bI nr
JOBSITE ADDRESS re - �y.eS.�°14s as ._I OWNER'S NAME[ Q_ .M�HoN _ 1
OWNER ADDRESS L _JTEIIGI _PAX I
TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL 0 RESIDENTIAL
PRINT '
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• CLEARLY NEW:0 : RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES O _NO PJ
APPLIANCES-1 FLOORS-. BSM 1 2 3• 4 5 6 7 ' 8 9 10 11 12 13 14
BOILER - I _ .I!.__. JL._._., L ilI . .. ' ... 1 ;I__.._ 'I _,I._, ,''__ _ !I_ _ _:i_.. _+I__,.. i
BOOSTER : , . I _.I{_ - 11 __i _. ! li_ ___L.._. II_ JI__ _-' --- i.-- - 'I- __I_- 1__-.I . _ '
• CONVERSION BURNER H __JrAL._,._ir _
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COOK STOVE" _
DIRECT VENT HEATER III .;fl iL�' 'I
•. DRYER __. 1--- il- --IL __fl — rut--;11_-_�I—��i� !� �'I_ _ I , ';__ !_._R
FIREPLACE _ I--_` __ - I_T- r 11
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FRYOLATOR- . . _ ,, , . I . .- _
FURNACE
INFRARED HEATER
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ROOF TOP UNIT I ' Ill, -- - - - --
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UNIT HEATER E
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UNVENTED ROOM HEATER
WATER HEATER _ �® Gij
OTHER 4,J1111• W
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INSURANCE COVERAGE sy ---' --------'
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li]NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a'. --- OTHER TYPE INDEMNITY Q ` ' ' 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: OWNER 0 AGENT 0
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. A 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. /
PLUMBER-GASFITTER NAME I Joseph Ventresca -- �_J LICENSE ail SIGNATURE
MP 0 MGF 0 JP 0 JGF 0 LPGID CORPORATION 0# 3255 I PA RSHIP0#_ . -- ,_I LLC Q# -
COMPANY NAME:I South Shore Heating and Cooling J ADDRESS 157 Whites Path .__J
CITY l South Yarmouth 1 STATE MA ZIP 02664 TEL 508398-6901A _ 1
FAX LEIE6a6.11A CELL 508360-5277 EMAIL[joe@southshoreheafng000ling.com s_aii
-thi toll 2
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT#
PLAN REVIEW NOTES