HomeMy WebLinkAboutBLDG-20-000908 9'--) , 'LDS
_ ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.24 AY hO�,AD CITY south yarmouth MA DATE 8/1/2019 PERMIT# , —�L'0`?'$.
JOBSITE ADDRESS 59 cove view dr OWNER'S NAME MITROKOSTAS KONSTANTINOS
GOWNER ADDRESS TEL 6174473535 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
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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 I 12 13 14
BOILER J 6 (1 U I ((
BOOSTER ll 11
U CONVERSION BURNER I 1 ll U
COOK STOVE I I 1 U +—A.'
DIRECT VENT HEATER I 1 11 ( I 1
DRYER L. . I _
FIREPLACE L .,
FRYOLATOR J I U U t 1
[>( FURNACE x ll 1
GENERATOR
GRILLE 1 11 1 U 1
INFRARED HEATER I I U I) 11
LABORATORY COCKS 11 U I, U
MAKEUP AIR UNIT J 11 11 11
U
OVEN 1 11
POOL HEATER t U U U
ROOM/SPACE HEATER
ROOF TOP UNIT �[ 11 ( ; 11 1 1 (i
TEST IQ1 U ( U U
UNIT HEATER J O U 1 J f 1 U
UNVENTED ROOM HEATER U. 11 1
WATER HEATER J U U I I 4 i •
OTHER I 1 11 I J U 1 U U
I II I 1 I U L ll U
1 lI U I U t i �� U
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ONO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY H OTHER TYPE INDEMNITY ❑ BOND U
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 accur to th owledge
and that all plumbing work and installations performed under the permit issued for this application will be in comps e i all e provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 SIGNATUR K
MP 0 MGF❑ JP❑ JGF❑ LPG! CORPORATION❑# 3698C PARTNERSHIP LC❑#
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
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