HomeMy WebLinkAboutBLDG-16-003188 ��� 6
MA USETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
m a1 CITY I S �M_ n- MA DATE �� 1 :..1 PERMIT#/`?�P17 /(o—a)��g�,
I t-- 1
JOBSITE A ESS # 1?..1212
,._ (�t. __ OWNER'S NAME d�.__ 1�F 11✓!!�,__.__; - ..:�G _ _ _
OWNER ADDRESS f
TYPE OR OCCUPANCY TYPE COMMERCIAL 1i EDUCATIONA 71 RESIDENTIAL[
PRINT u
CLEARLY NEW:I„.m_,., RENOVATION::1 REPLACEMENT:
1-7 PLANS SUBMITTED: YES .] NOID
APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER r_____. i --. — __• — ,,._ _
BOOSTER r -
CONVERSION BURNER i I ,-- i� ', —
�a
COOK STOVE r ! ' -
—
DIRE
DR YE
VENT HEATER _ ; Ei— = �3 . ,..
FIREPLACE
FRYOLATOR --- ;, i [
FURNACE
- _, = _ _ ini . .
{
GENERATOR
_
GRILLE t
u:.ti . ..:m 3
INFRARED HEATER ' ;— �_
LABORATORY COCKS _�
MAKEUP AIR UNIT [ I I I I
OVEN _ _ I _
POOL HEATER r �.t. � t - � ' r l�
,,- tea!
ROOM/SPACE HEATER _ _ , I
ROOF TOP UNIT " _
l:
. �._ __�,... .,_ �,.
TEST - x
UNIT HEATER t
UNVENTED ROOM HEATER
WATER HEATER = .� ; I�
OTHER M I
{ 1
x , �
I
w r--= m
i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO (. ii
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LA t OTHER TYPE INDEMNITY [] BOND I 1
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 00 AGENT 0
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.ance Pet provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Famham [ LICENSE#111601^ ,SIGNATURE
MP MGF LI JP C JGF LPG'0 CORPORATION ✓ # (p 3 G PARTNERSHIP #E µ 1 LLC UI# i
COMPANY NAME: South Shore Heating&Cooling,Inc €ADDRESS C57 White's Path _ �_ �_ _.___
CITY (South Yarmouth —I STATE[ MA--ZIP 02664�� �TEL[508-398-6901
FAX 508 760 2681 I CELL IEMAIL((
t ` hi.,