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Home My WebLink AboutBLDG-22-006976 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •w CITY IYARMOUTH I MA DATE 'June02,2022 (PERMIT# BLDG-22-006976 In JOBSITE ADDRESS 1118 CLEAR BROOK RD I OWNER'S NAME SWANN RICHARD E G OWNER ADDRESS SWANN KATHLEEN M 118 CLEAR BROOK RD WEST YARMOUTH MA 02673 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO El 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 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY INSURANCE POLICY© OTHER OF INDEMNITY ID 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# 11601 SIGNATURE MP©MGF❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: South Shore Heating&cooling ADDRESS. 157 Whites path, CITY South Yarmouth STATE MA ZIP 02664 TEL I5083986901 FAX CELL EMAIL I S310N M3IA321 NVId #lJVV2I3d $ :33d ❑ 0 111N2:13d 3H1 SV S3A213S NOIIVOIlddV SIM. oN saA S310N N011O3dSNI 1VNH A1N0 3Sf1 10103dSNI 2JOJ 39Vd SIH1 S310N NOI103dSNI SV9 H9f102!