HomeMy WebLinkAboutBLDG-20-001946 �v
MASSACHUSETTS0N|RORM APPLICATION FOR A PERMIT TOPERFORM GAS FITTING WORK '
CITY !lYammu� �A DATE 1O�2�O10 PERMIT �«���
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JOBS|TEADDRESS 5G Blue Rock Road OWNER'S NAME Roger Gardiner
OVVNERADDRESS SAME TELSO8'304'6538 FAX
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TYPE OR
0CCUPANCYTYPE COMMERCIAL| | EDUCAT|0NAL �l RES|DENT|AL�l
PRINT �� ��
CLEARLY NEyy:[-1 RENOVATION:Fl REPLACEMENT:Fl PLANS SUBMITTED: YESFl N0E-,,l
APPLIANCES 1 FLOORS— uom 1 2 3 4 5 0 7 O S 10 | 11 12 13 14
BOILER
BOOSTER
-j �|
CONVERSION
/
COOK STOVE |
DIRECT VENT HEATER `
DRYER
| ] �
FIREPLACE
FRY0LATOR
FURNACE
��E�T�
c�~
GRILLE
INFRARED HEATER U ',
LABORATORY COCKS |
MAKEUP AIR UNIT
OVEN ^
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT j
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER | | |
|
OTHER | | |
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INSURANCE COVERAGE
|have o current Uoh|dv insurance policy or its substantial equivalent which meets the requirements nyMGL Ch.142 YES NO �l
||F YOU CHECKED YES,PLEASE INDICATE THE TYPE-OF C0VERAr-EBYCREECKING THE APPPOPRtATF BOX BELOW
LIABILITY INSURANCE POL|CYE] OTHER TYPE INDEMNITY R BOND F-1
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter i4Jofthe
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F_� AGENT71
SIGNATURE OF OWNER ORAGENT
/hereby certify that allm the details and information|have submitted v,entered regarding mm application are true and accurate to!he b9st of Ty xnwwoogo
and that all plumbing work and installations performedunuv,momonnn/xououm,mivappooauvn will be in com with a I Perline provis of the
Massachusetts State Plumbing Code and Chapter 14om the General Laws.
PLUMBER,GASF|TTERNAME Ke�hJ.Fum � ,Farnham LICENSE 118O1 UF�� /
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�P � �GF� JP�� JGF[-1 LPG|�-1 CORPORATION�
N �# 3888C PARTNERSH|P�-l# ~ LLCF_j#
COMPANY NAME: South Shore Heating&Cooling,Inc ADDRESS 67 White's Path
CITY South Yarmouth � ^� � '. �STVTE ' MA ZIP 02664 TEL 608'398'8801
FAX SN 60-2881 CELL EMAIL \ . (} 0/)0\\
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