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HomeMy WebLinkAboutBLDG-22-005848 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fli: CITY YARMOUTH ViMA DATE April 13,2022 PERMIT# BLDG-22-005848 Ft JOBSITE ADDRESS 210 SOUTH ST OWNER'S NAME FONTAINE LESTER E TR G OWNER ADDRESS THE L&C FONTAINE NOM TRUST 510 COTTAGE ST SPRINGFIELD MA 01104 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER i I WATER HEATER I OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME keith farnham LICENSE# 11601 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Souh Shore Heating&Cooling ADDRESS. 57 whites path, CITY souh Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL S310N M31A32i NVId #11W2i2d $ :333 ❑ ❑ 1I11U3d 3H1 SV S3M3S NOIlV3Ilddv SIHL oN seA S310N NO1103dSNI IVNId AINO 3Sfl lO103dSNI 2IO 139Vd SIHI S310N NOLLO3dSNI SVJ Enna!I