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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
M l�z CITY ' ] MA DATE 1 PERMIT#/. �16v OOd QO•fjr
JOBSITE A SS�srn _- _:�._ - OWNER'S NAME 1U,t _...f -\��G �:... ._.��::
OWNER ADDRESS _ _ _ TE S11 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL E RESIDENTIAL /
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CLEARLY NEW:[j RENOVATION:[1 REPLACEMENT: PLANS SUBMITTED: YES 0 NO--
APPLIANCES- FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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DIRECT VENT HEATER 11111111111111
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POOL HEATER - . -._ CIMMWOIN
ROOM I SPACE HEATER _. _( hII MI
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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 k'9 NO i_
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I v OTHER TYPE INDEMNITY trmm=i BOND L
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 H
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 Pe • t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (/f
.41(44
PLUMBER-GASFITTER NAME I Keith J.Famham LICENSE#111601 ffi j SIGNATURE
MP;,� MGF L .. JP' I JGF( 1 LPG! CORPORATION( # 79(`f G PARTNERSHIP 1, I#r LLC _#
COMPANY NAME I South Shore Heating&Cooling Inc 1 ADDRESS 157 White's Path
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CITY
I South Yarmouth 1 STATE MA ZIPr 02664 TEL 508 398 6901 I
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FAX!508 760-2681 1 CELLI IEMAIL T 1