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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY south yarmouth MA DATE 6/25/2018 PERMIT#
JOBSITE ADDRESS 19 ocean ave OWNER'S NAME jane joncas
GOWNER ADDRESS TEL 9329761 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW:O RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
APPLIANCES Z FLOORS-' BSM 1 2 3 4 5 6 7 8 9 r 10 11 12 13 14
BOILER Q- II 0 U11 U U
BOOSTER 11 (�� u j t
CONVERSION BURNER
COOK STOVE Q 4 I D . U 4 U 1
DIRECT VENT HEATER 11 U If U I U 1 U
DRYER 11 11 I U J 11 U U U I�
FIREPLACE
FRYOLATOR UU 11 II U 0 U 1
FURNACE x
GENERATOR 1 U 11, 11 II
GRILLE U ,U U 11 11 11 U -11
INFRARED HEATER 1U 0 11 U 4 U
LABORATORY COCKS 101Q111
MAKEUP AIR UNIT U U _ I . U 11 4. 11 U
OVEN 11 `
POOL HEATER D U Ui1111 .11
ROOM/SPACE HEATER U U U 1( U 11
ROOF TOP UNIT L. -
TEST �.
UNIT HEATER U'I 0 U .1111 L U- I' U
UNVENTED ROOM HEATER U II 11 U U U U. U }J jt
WATER HEATER fl U _ . U ll_
OTHER U U__ U__. U U U... U �I i
I 11 11
!I 11 1 11 11 11 11
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q 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 a acc rat es o y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli ce wi all erti e provi n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE# 11601 IGNATURE
MP 0 MGF LI JP❑ JGF❑ LPGI❑ CORPORATION Q# 3698C 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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