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1 ' 't MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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` IAT z CITY Yarmouth MA DATE 12/17/14 PERMIT# /Y-Per-le CO 370.,
JOBSITE ADDRESS 79 Bamicle Rd. I OWNERS NAME Ann Smith
GOWNER ADDRESS SAME I TEL 508-362-2357 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:El (5... PLANS SUBMITTED: YES❑ NOD
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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GENERATORFURNAAE s 'i_
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INFRARED HEATER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ 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 ❑ 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 andndaccu e to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be In complia with II P�iineet provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. %/ff' I
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PLUMBER-GASFITTER NAME Keith J.Famham I LICENSE# 11601 I SIGNATURE
MP D MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑+ # 3698C PARTNERSHIP❑# LLC❑#
COMPANY NAME: South Shore Heating&Cooling,Inc ADDRESS 57 White's Path
CITY South Yarmouth I STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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