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,.i' ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ID yn J.I. j CITY south yarmouth MA DATE 12/26/2018 PERMIT#/k- 'Y9—GO -59°1 5
JOBSITE ADDRESS 733 willow st OWNER'S NAME barbara commons
GOWNER ADDRESS TEL 5082801880 (FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONALRESIDENTIAL
PRINT ❑
. CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:a PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER rI 1 i
BOOSTER ;, I, i, i 1
CONVERSION BURNER i II i i_
COOK STOVE 1 _-r - 1
i ii
DIRECT VENT HEATER ; - I I o I � I i
DRYER ;M.l II I ri(—Iii'
;I�n—I
• FIREPLACE
FURNACE ° ii.
FURNACE xi
GENERATOR
GRILLE i
INFRARED HEATER
l '1
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN I d
POOL HEATER 1
ROOM/SPACE HEATER Ili-
n ,
ROOF.TOP UNIT �i; ,, l; j
TEST
UNIT HEATER
UNVENTED ROOM HEATER 111111
�r i 1i i� d 10 WATER HTER x
OTHER r , o o •
I
li i
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 ONO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I • 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 El 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 - • accur-te •th e •-st o m knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In corn.'.: ce wit•/-II - ision
rt• e t• ovof the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A
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PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE# 11601 / SIGNATURE
MP a MGI❑ JP❑ JGF❑ LPG'El CORPORATION I# 3698C PARTNERSHIP■# 'Ica
, COMPANY NAME: South Shore Heating&Cooling, I ADDRESS 57 White's Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL
Lk 8-
F711/;9-
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