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HomeMy WebLinkAboutBLDG-22-004501 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Nf CITY YARMOUTH MA DATE February 14,2022 PERMIT# BLDG-22-004501 JOBSITE ADDRESS 10 LOOKOUT RD OWNER'S NAME JARVIS MICHAEL G OWNER ADDRESS JARVIS LINDA 110 CLUBHOUSE LN NORTHBRIDGE MA 01534 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 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/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 0 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❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: South Shore Heating and cooling ADDRESS. 57 Whites Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL S31ON M3IA321 NVId #1IWN3d $:33d ❑ El 11110nd 3E11 SV S3tH S NOI1VOIlddV SI HI oN seA S310N NO1103dSNI 1VNIH AINO 3sn a0103dSNI aOd 30Vd SIH. S310N NO1103dSNI SVO HOflO