HomeMy WebLinkAboutBLDG-22-005781 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 'YARMOUTH I MA DATE (April 11,2022 I PERMIT# BLDG-22-005781
JOBSITE ADDRESS 128 SOUTH SEA AVE I OWNERS NAME PACHECO STEPHEN J
G OWNER ADDRESS PACHECO BARBARA E 28 S SEA AVE WEST YARMOUTH MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0
PRINT
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
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 _
GENERATOR 1 _
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT _
TEST 1
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 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY BOND ❑
OWNERS 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 keithfarnham LICENSE it 11601 SIGNATURE
MP El MGF❑JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME: Souh Shore Heating&Cooling ADDRESS. 157 Whites path,
CITY South yarmouth STATE MA ZIP 02664 TEL 15083986901
FAX CELL EMAIL
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