HomeMy WebLinkAboutBLDG-16-000324 -77.7-.41.-- (//11(-)-(T-7) 6
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PER TING WORK
,CT-I,
t-lii J CITY k, Lk \ MA DATE r7 PERMIT# / ✓ir-lb XiOD '
JOBSITE ADD ssL2 at t ►:1-10 • OWNER'S NAME --t Y,J 1' Id CA
GOWNER ADDRESS --I TEL 1-ik-i.353-VE(5 IFAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL 1 ( ,_ RESIDENTIAL Er
PRINT
CLEARLY NEW:U RENOVATION:Li REPLACEMENT:®/ 50 PLANS SUBMITTED: YES® NO®
APPLIANCES- FLOORS—► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER •
1
BOOSTER1
CONVERSION B - - lCOOK STOVE IN i S ripkiNOW l Oa
DRYERDIRECT VENT HEATER
pl, ,
FIREPLACE
FRYOLATOR
le Nil a
FURNACE nit Rik .
INFRARED HEATER IMS;NM;,W,MR NMI ,.I-� i.N WM WM WM Mili WWI MO
LABORATORY COCKS !NM MUM N MN LIM WSW M WM OM OM M[0MvAEKNEUP AIR UNIT ialM, _ • ,_,= 1,miiiii i gigingt,Eirr
POOL HEATER Irarmiar4 unnat
ROOM/SPACE HEATER "4M,- P
mAR,Ap I 1,,,,m714
ROOF TOP UNIT MIM Mit --—WM
iim
TuENs1TTHEATER 15n111141-11111_ 1 in..,LIIIIIIII,
I i
irEniMirlMrt,
WATE '.:; •-s,•, -•, ' _. r .., - , — _ WspinionwiWe rlg
OM
WM NM NM int MO
OTHE' Ur ih__ Ili i wigMI,WM WIMIMMIN MINI 1111.WNW OM MN MIN OM NMI
iL.,. INSURANCE COVERAGE
I have •curren is•i i insurance po icy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ,,,,,,irj OTHER TYPE INDEMNITY (_ j 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 Li AGENT Li
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 that all plumbing work and installations performed under the permit issued for this application will be in comp'anth* Pef'aept provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -41.44
_ G
PLUMBER-GASFITTER NAME Keith J.FamhamM LICENSE#�116014. SIGNATURE
MP El MGF ID JP Li JGF Li LPG'L j CORPORATION Ei# 3vii C]PARTNERSHIP LJ# —1 LLC LP
COMPANY NAME: South Shore Heating&Cooling,Inc ADDRESS 57 White's Path I
CITY South Yarmouth 1 STATE rMA ZIP 02664 TEL 508-398-6901 I
FAX 8g760 2681 CELL _ EMAIL