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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-®k1 CITY Igi wilrlll I,�(�,� MA DATE PERMIT# DtDk/Jtoo n18"
G JOBSIT ADDRESS Ill 1 IVk7 �_1/�ZZi— OWNER'S NAME gitm /f7 Jjm i i it
OWNER ADDRESS TE93a2:24i FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL❑ RESIDENTIAL
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CLEARLY NEW:El RENOVATION:❑ REPLACEMENT:L(d' PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1. FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
50
BOOSTER 1----11--
CONVERSION BURNER I 1 1-----
COOK STOVE II '� —
DIRECT VENT HEATER l AI IJ . _i
DRYER , ... 1 ( II 11 —
FIREPLACE — I it —1— d
FRYOLATOR -
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FURNACE r I_ — — —
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PD GENERATOR I I I I,
GRILLE W r. — 1
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INFRARED HEATER f I1— 1—'d' - --Ji— — —
LABORATORY COCKS ,1 1i L. .� i I-
MAKEUP AIR UNIT
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OVEN I 1 il 1 IIIA , 1 1
POOL HEATER I _ I - fl _' 1 1
ROOM ISPACE HEATER I II I iP k it P I 1
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ROOF TOP UNIT I—_ ' � I I r i �I r I I 1 I
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MM.il NK RTMENT dI 1 1 'I .I 1 t ';I 'I 'I I I
Br __t - 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 ❑
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 comp'ance PeAinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (/b
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE#5T6.1371-1 SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPG(❑ CORPORATION d#15(D7(q Ci (PARTNERSHIP❑# I 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 I
FAX 508-760-2681 I CELL EMAIL
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