HomeMy WebLinkAboutBLDG-20-002613 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT .O PERFORM GAS FITTING WORK
— 1 t MA DATE 5� i Qt PERMIT# ,,K//CT-olf�-(5d�4l�=_�Ii=—,� CITY yil-�/�1�v � � 4 Zl1
JOBSITE ADDRESS 5 id HIS cs�2' Ln1. + OWNER'S NAME VTRC1 i�W)- gegr✓�2S
GOWNER ADDRESS }/A-J`rrt o `L p D _ 1:TEL 73 t riFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL__I EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:® REPLACEMENT:Er PLANS SUBMITTED: YES® NO Iir
APPLIANCES Z FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER II. I 1 -- I I_
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER �..__ - I . .. __. .-.l ..-:I - I
DRYER INN I
FIREPLACE I I !
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS l MAKEUP AIR UNIT
OVEN I-_,j. 1
POOL HEATER ' I �'I_
ROOM I SPACE HEATER �._ a !_m. J m. . _r
ROOF TOP UNIT
TEST `I_ I .° �s ' '' = - I
UNIT HEATER �.
UNVENTED ROOM HEATER _... :f ____ .„ L
WATER HEATER tL IL,_ ,1 t'_
OTHER __._._- ___ .--_ __ _
v 6Y INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I OTHER-TYPE INDEMNITY-7 - 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: 0, NER D 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 .t o y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp. e wi .I rti nt pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE# 11601 , GNATUR
MP E1 MGF ._...I JP -_J JGF ,• LPG! _a CORPORATION 171# 3698C ' PARTNERSHIP # LLC #
COMPANY NAME: South Shore Heating&Cooling, Inc -- ADDRESS 57 White's Path
CITY South Yarmouth STATE MA ZIP�02664TEL 508-398-6901
FAX 508 760 2681 CELL 'EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES -r-'��114" 6/
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