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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
M tl� CITY I F-> `- v qr‘1,1\a t, I MA DATE L1/4-- ` It PERMIT# e-4O 4grot
JOBSITE ADDRESS \ k\i‘sts I OWNER'S NAME \_\v\a v
GOWNER ADDRESS TEL Sc%-310tic_- SSI FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL _ RESIDENTIAL ij
PRINT
CLEARLY NEW:Li RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES® NO 0
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 i
DIRECT VENT HEATER �J
DRYER
FIREPLACE
FRYOLATOR I I I I " I I
FURNACE
GENERATOR _�f
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER _ I
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 0 NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY rij OTHER TYPE INDEMNITY ® BOND Li
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 Li AGENT Ej
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 ac ra tote hest of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in coe • P anent provisn of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE# 11601 I SIGNATURE
MP MGF Li JP® JGF® LPG'® CORPORATION Li# 3698C PARTNERSHIP®# LLC D#
COMPANY NAME: South Shore Heating&Cooling, ADDRESS 57 White's Path _
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL 'EMAIL �n�Q SUllr��1->CP�efirYaCG���✓•CC�G�-,
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