HomeMy WebLinkAboutBLDG-19-007293 l-� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CEi4 CITY V O I^r 1 MA DATE Vca f//7 1 PERMIT#1 ,/7-CC? 742?1
-
JOBSITE ADDRESS 5..._.. ws __ L OWNER'S NAME '1r ie. ez-3-5-
GOWNER ADDRESS f 3" G �� TEL FAx
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ID RESIDENTIAL ----
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO0
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
. -..-1 ( I I
BOOSTER
CONVERSION BURNER i I
COOK STOVE
DIRECT VENT HEATER 1 1 1 ,,,1, . , k _
DRYER 1 1 1 I I t I
FIREPLACE ! _—.. ___, _ , .._ .._ .._
FRYOLATOR 1 !_ 1iimuirR
•
FURNACE , . _._ , , I ,..
GENERATOR
GRILLE
INFRARED HEATER . . . ._. . �. ;.. a _ _
LABORATORY COCKS ., '
MAKEUP AIR UNIT 1 1 1 1_ 1 i
OVEN 1 1 1 I 11., ,,_.. I .I,. ._ _ _
POOL HEATER I_ 1.. . t I ,, .ROOM/SPACE HEATER I . .I ' .,_ I
ROOF TOP UNIT _ r 4
TEST
UNIT HEATER I ' 1
UNVENTED ROOM HEATER I
WATER HEATER
S� OTHER s / j3it I
.- .� ,. /.,w �� � I_ EMI. .. '�06.„ 1 1 11
11111Milanurniumwr
IOUS 1
..... ..._
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY Q BOND 0
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 El
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 c ra e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compf e h P rtinent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 SIGNATURE
MP Li MGF 0 JP 0 JGF 0 LPGI® CORPORATION L]# 3698C PARTNERSHIP LJ# LLC E# 1
COMPANY NAME: South Shore Heating&Cooling, 'ADDRESS 57 White's Path 1
CITY South Yarmouth STATE MA ZIP 02664 'TEL 508-398-6901
FAX 508-760-2681 • CELL EMAIL /
a
0 �
ti
ti
C�-
0 �
�5