HomeMy WebLinkAboutG-20-1888 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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"h CITY west yarmouth MA DATE 9/26/2019 PERMIT#h406--A0'oo air
JOBSITE ADDRESS 74 trowbridge path OWNER'S NAME gloria gage
GOWNER ADDRESS TEL 3392061261 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER x ! e I I C 1 I ,
BOOSTER
CONVERSION BURNER U II L III 11 I I I
COOK STOVE 1 0 l ` I Ir 1 0
DIRECT VENT HEATER U U I I U U 1 I 11
DRYER 11
U I � I U I ll - I
FIREPLACE
FRYOLATOR 1.1 it I U U IJ i U
FURNACE `--1
GENERATOR
GRILLE 1 11 IJ 1J I U U I U 1 U -
INFRARED HEATER (j [j IJ 1 11
LABORATORY COCKS 11 I i i''
MAKEUP AIR UNIT I U II U U U U 1 U
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POOL HEATER I II U
ROOM/SPACE HEATER 11 II —1- _
_ROOF TOP UNIT I
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UNIT HEATER 11 1 1
UNVENTED ROOM HEATER T 1
\ WATER HEATER x I t 1
OTHER U U I1 U 1 U I U t
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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 I v I OTHER TYPE INDEMNITY ❑ 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 acc ate the y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp ce wit all rti %}sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,a /-t�!_
PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 SIGNATURE
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MP 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION 0# 3698C PARTNERSHIP❑# LLC❑#
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 info@southshoreheatingcooling.com
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