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HomeMy WebLinkAboutBLDG-19-002268 4 50 • CDC) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK It—1nr—C' ;,trlirr CITY Yarmouth Port 1 MA DATE 10/12/18 PERMIT#&Po/9-O& a(� JOBSITE ADDRESS 32 John Hall Cartway OWNER'S NAME Randy Fine GOWNER ADDRESS SAME TEL 518-368.1379 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW:ID RENOVATION:❑ REPLACEMENT:a PLANS SUBMITTED: YES ID NOD APPLIANCES 7 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 r - BOILER -II I- ,i BOOSTER I I II CONVERSION BURNER J COOK STOVE I DIRECT VENT HEATER , DRYER FIREPLACE I FRYOLATOR _n FURNACE 1 GENERATOR , GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNITt`• I OVEN _ill ..t .__j'sftl POOL HEATER ROOM/SPACE HEATER r ROOF TOP UNITI I % TEST UNIT HEATER u` I` nr —.I v IT li UNVENTED ROOM HEATER WATER HEATER I . OTHER a 1 I _. ; I 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliwith all P rtine ovisio9,of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Keith J. Famham LICENSE# 11601 / SI ATURE MP Q MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION D# 3698C PARTNERSHIP❑ I LLC❑#IIIIIIIIIIIII COMPANY NAME: South Shore Heating&Cooling,Inc 1 ADDRESS 57 White's Path CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901 _ u_ FAX 508460-2681 . CELL _.. ...... ,aEMAIL, LR- •t 67t19 i(X-r LIEU /aA7/