HomeMy WebLinkAboutBLDG-15-005797 f y-\ CUI w�\-� 80
" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY South Yarmouth ___ I MA DATE 01/21/15 I PERMIT# j.�pf/y^OdJ`-f f
JOBSITE ADDRESS 18 Mistletoe Lane OWNER'S NAME Barbara Clancy
G _J TEL 508-760-4967 FAX OWNER ADDRESS
TYPE OR OCCUPANCY TYPE COMMERCIAL _I EDUCATIONAL ,J; RESIDENTIAL J
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CLEARLY NEW:' II RENOVATION: REPLACEMENT: vI PLANS SUBMITTED: YES_J NO___I
APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _ _J- __J .J I _I._..._..._I_.1 _...LI I I ___I___._..J I..
BOOSTER . ... __J ... .m... .._I . __ _I .,-___I ... _..., _.
CONVERSION BURNER _ I_I i _I_ _I _ _.. _._.....J _�.I ,..... I I_I.__J
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COOK STOVE , _I__ I J J ®.I___I ._�I_ . .
DIRECT VENT HEATER J''..� ._�.._J" I _.__-.J. -__.I .. I . . , I ___J I I J I
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FIREPLACE I _ I _.,E .�_J J'__J._.,. , J J I _ J I i
FRYOLATOR . _ ®�_L _I _E I _ I_ I� I _► _ _._.......,...I
FURNACE _I ..._-_. I'__I J, J w: 1 .,J__I_I _ _ _ _... -.I
GENERATOR I i 1 I J J I J_I_®J I ,,.J__,I_.4_oJ
GRILLE ....1. J ._J __._.J J . ..J J J ., I _ .
INFRARED HEATER __ I� J I l J __ _�I �I _. ®I _ I___J I
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LABORATORY COCKS I __J�___, r _I .. __ I.__...._I_ .u..,.i -J J I
MAKEUP AIR UNIT s _ ;'_ m_J __,..1 _J_J ___J'', ��.I J _ ..�._ .1
OVEN . _J -__-. __ I . J_ J i I ____1 _.___....I ._ I __n....J _I _
POOL HEATER ... I J _J _1 ►_ i
ROOM/SPACE HEATER J _ -.._.J w I _ J _I_ I ._..._ . _.I_ I .___. ___�I I __IROOF TOP UNIT I . _. .,1 ____I _I ____I. __.. I __ J J _I
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TEST I_ .�_� : I ___.1____.1 __ _ J_ --_ _ _J I s
UNIT HEATER _I __IJ , I m..;I _. , J .. .I. „...,..4y __I _,. I .�_ J
UNVENTED ROOM HEATER E J _ I . I I_ _ E___I I.. . I _1 _1 I
WATER HEATER _ 1 t _,...;!._._,. _ ,,.. I I _._I__��_.._I ..__J .. .J .�. I_.I.. .I __.®_. _
OTHER I 1 __I. 1 _ 1 I __I .. . I J _____I __,,,,I_
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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 A NO L
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ,! OTHER TYPE INDEMNITY BOND ___I'
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 _..I AGENT L
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 accurate to the best of my knowledge
and thasac all tts State
work andininstallations performedpter1 of the
hethe permit issued for this application will be in complia ce wi all I: ineRt• ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i/ C�
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PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 1 SIGNATURE
MP ./J MGF __I JP . JGF __,I LPGI I CORPORATION ! # 3698C '-PARTNERSHIP I# E LLC #
COMPANY NAME: South Shore Heating&Cooling,Inc �ADDRESS 57 White's Path
CITY South Yarmouth _ _.j' STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 I CELL 1 EMAIL �'