HomeMy WebLinkAboutBldg-19-006552 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
+.fl( - CITYyhfptoleki MA DATE �`/ PERMIT# !/�-/✓// Ceg. v<
JOBSITE ADDRESS Zifleprizett. #0 ,.01-1 E�
_WNER'S NAME A Ls' �C
GOWNER ADDRESS leav7 TEL `y+'AX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Li RESIDENTIAL[
PRINT
CLEARLY NEW: RENOVATION:L REPLACEMENT:Li PLANS SUBMITTED: YES Li NO T� '
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _ --
BOOSTER I }
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR _
FURNACE i 1
GENERATOR —i!
GRILLE
INFRARED HEATER
LABORATORY COCKS I
MAKEUP AIR UNIT
OVEN I
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT _
TEST
UNIT HEATER _
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ,ri' 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 1 AGENT ` I(
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 an rate est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli w rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J. Farnham , LICENSE# 11601 SIGNATURE
MP �. MGF r JP JGF ] LPG' 7 CORPORATION m#3698C PARTNERSHIP®# LLC Ej#
COMPANY NAME:LSouth Shore Heating&Cooling, Inc ADDRESS 57 White's Path
CITY 1 South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL VC 4C) e ` s111(We r ,c,C Srcol
he/I-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES