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HomeMy WebLinkAboutBLDG-23-000125 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH MA DATE (July 08,2022 I PERMIT# BLDG-23-000125 JOBSITE ADDRESS 153 DRIFTWOOD LN OWNERS NAME MCCLAY CAROL ANN TR G OWNER ADDRESS THE CAROL ANN MCCLAY LVG TRUST 153 DRIFTWOOD LN SOUTH YARMOUTH TEL MA 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO El FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El 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 Famham LICENSE# 111601 I SIGNATURE MP©MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: South Shore Heating&Cooling ADDRESS. 57 Whites Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 15083986901 FAX CELL EMAIL S310N M31/13b NVld #iIW2j3d $:33d ❑ ❑ 111Ab3d 3H1 SV SR/V:13S NOIlVOIldd`d SI1-11 oN saA S310N NO1103dSNI 1VNId AlNO 3Sf1 b0133dSNI 2103 3OVd SIH1 S31ON NOLLO3dSNI SVD HJflOb