HomeMy WebLinkAboutBLDG-19-005655 '. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t -,11—a CITY yamiouthport MA DATE 3/8/2019 PERMIT# /f-Jf -/7- 5-Y
JOBSITE ADDRESS 53 arthur lane OWNER'S NAME eleanor krake
GOWNER ADDRESS • TEL 3629661 FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
t BOILER x 1 1 0
BOOSTER j I 1 1 d, tl
CONVERSION BURNER I 1 [ 11 1 I I 11 11
COOK STOVE I 1
DIRECT VENT HEATER
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DRYER ��IRRRR
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FIREPLACE • �R1
FRYOLATOR
FURNACE , r
GENERATOR 1 -
GRILLE 1ij '! 1 U
INFRARED HEATER 9 I jj _ 1 1 1 Ii
LABORATORY COCKS 1 1 I Q
MAKEUP AIR UNIT j _ ii 1 1 „ U
OVEN ' ft ! j 1 I U
POOL HEATER 1 t
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ROOM/SPACE HEATER ! (f
ROOF TOP UNIT �� j If
TEST , U
UNIT HEATER I 1 1 1I 11
UNVENTED ROOM HEATER 11
WATER HEATER i
OTHER
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1 l 1
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 0 OTHER TYPE INDEMNITY ❑ 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 ❑
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 a d a a tot my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp' ce ine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPGI 0 CORPORATION Q# 3698C PARTNERSHIP[t# LLC❑#
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 Iy O •SC3U4-hShOrt erAi 1G000 the • COhr
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