HomeMy WebLinkAboutBLDG-19-006551 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY pa-Jen p()V ek,., MA DATE sP/ te? 'PERMIT# /T"/p—& Gob
JOBSITE ADDRESS 4-2(j jCk (//.tI fJ. 0 cli R'S NAME ate- +((;1)y u c.' I
<T OWNER ADDRESS U. y/AP/no k- TEL a60-0397 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL El
PRINT
CLEARLY NEW:® RENOVATION:® REPLACEMENT:Ie.._ PLANS SUBMITTED: YES® NO[be°.
APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I I
BOOSTER L j
CONVERSION BURNER I I
COOK STOVE
DIRECT VENT HEATER I
DRYER I y
FIREPLACE I I
FRYOLATOR
FURNACE I
GENERATOR I
GRILLE
INFRARED HEATER L i
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER I l
ROOF TOP UNIT Ii
TEST
UNIT HEATER I i i
UNVENTED ROOM HEATER LI
WATER HEATER L
OTHER
IRR "MR!.
P.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY BOND E
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 Ej
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 compliance with aJLPerttnent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a�7c-ae .�
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE#�11601 � SIGNATURE
MP 0 MGF❑ JP El JGF[J LPG] CORPORATION Q# 3698C PARTNERSHIP❑# LLC LJ#
COMPANY NAME: South Shore Heating&Cooling,Inc ADDRESS 57 White's Path
CITY South Yarmouth STATE ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL I' () • S( -1hsl' vehf(,—b 9 <An ii.r � -Glam?--
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINALL INSPECTION NOTES
Yes No l h 7 t,..1., c.es-
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# ok
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