HomeMy WebLinkAboutBLDG-15-002773 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSI ADDRESS[,MI Annaba � W,i] OWNER'S NAME [till Ter\ t L�,(�[/ n
GOWNER ADDRESS TELI-555161:11101FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDU ATIONAL U. RESIDENTIAL[3
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CLEARLY NEW:al RENOVATION:CI REPLACEMENT: Le PLANS SUBMITTED: YES❑ NO❑
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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 0 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 D
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 accuratea� to the best of my knowledge
and that all usetts State
work andinInstallations performedptenunder thetGe permit Issued for this application will be in comp lance Peyaen provision of the
Massachusetts State Plumbing Code and Chapter 142 of General Laws. W.Si (/Jy - _....
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE 4111171 SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPG]❑ CORPORATION(f#5(0 CN G PARTNERSHIP❑# LLC❑#
COMPANY NAME: South Shore Heating&Cooling,Inc ADDRESS 57 White's Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL (EMAIL
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