HomeMy WebLinkAboutBLDG-20-000585 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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®gigty CITY south yarmouth MA DATE 7/23/2019 PERMIT# l'2' '000.' ,-
JOBSITE ADDRESS 39 four season rd OWNER'S NAME dorothy scarlett
GOWNER ADDRESS TEL 3985372 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL
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CLEARLY NEW:_ RENOVATION:ElREPLACEMENT:0 PLANS SUBMITTED: YES NOS
APPLIANCES 1 FLOORS—' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I U U U U U U j I 1 11
BOOSTER U U U U U U U ( U t
CONVERSION BURNER I U JJ U U U U U I II 11 I
COOK STOVE I I U U I I U U I I # U
DIRECT VENT HEATER 1 U U U U U U U I U U U
DRYER J U U U U U U U I U 11 U
FIREPLACE I 11 U I I I U I I I
FRYOLATOR .0 U U 0 U U U U I U U U
FURNACE J jf JJ U U U II U U I U U
GENERATOR I U U I I I I U I I I
GRILLE I U U U U U U U U U U JL
INFRARED HEATER MU U U U II U U U U U
LABORATORY COCKS I jf U It I I II U l I U 0
MAKEUP AIR UNIT U U U U U U U U U U ll
OVEN
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POOL HEATER
ROOM/SPACE HEATER U U U 11 U _ 'J
POOL
ROOF TOP UNIT J p I.
TEST IF i 1 _ _ —
UNIT HEATER I U U U
UNVENTED ROOM HEATER ( U U II U _ 1 1 I U IJ
WATER HEATER J x U U U II U U I I I U I
OTHER 1 U U U II U U I I U II I
U U III ll I I U U I
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I U U If 1 I I U ll I I
1 0 1 U II 1 U I I U U I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY I 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 ❑ 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 cura best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp O e III Perlyient provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,‘(
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE# 11601 SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION Q# 3698C PARTNERSHIP❑# Lc❑#
COMPANY NAME: South Shore Heating&Cooling, ADDRESS 57 White's Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL Inc 4 • 500-1-kEh0V.ehpCXf)h9 COO I1hC7 - CO/s-1
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