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_� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFOR _EITT-ING WORK
C.
' TY South Yarmouth 1 MA DATE 2/19/2015 J PERMIT# /✓L0^15---C615
JOBSITE ADDRESS 10 Nickerson Farm Rd !OWNER'S NAME Dunakin
GOWNER ADDRESS ,TEL 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIALLI
PRINT
CLEARLY NEW:Li RENOVATION:LI REPLACEMENT:❑ PLANS SUBMITTED: YES ID NOD
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER I
CONVERSION BURNER 1 ') I
COOK STOVE 11111
DIRECT VENT HEATER 1 1111111111
FIREPLACE
FRYOLATOR I j111..._. _�LI'
11
LABORATORY COCKS
MAKEUP AIR UNIT Mr ,.. I,
OVEN
POOL HEATER
ROOM/SPACE HEATER I 1
ROOF TOP UNIT
TEST
UNIT HEATER 1
UNVENTED ROOM HEATER
WATER HEATER 1 1 { _]]
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Li OTHER TYPE INDEMNITY Li BOND ID
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 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 and urate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in coo ence ith II P ainenw�on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1/
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE# 11601 1 SIGNATURE
MP Li MGF 0 JP(J JGF® LPG!Li CORPORATION L# 3698C PARTNERSHIP EP I LLC❑#
COMPANY NAME: South Shore Heating&Cooling, Inc ADDRESS 57 White's Path
CITY South Yarmouth 1 STATE MA ]ZIP 02664 TEL ,508-398-6901 1
FAX 508-760-2681 CELL EMAIL
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