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HomeMy WebLinkAboutBLDG-22-006942 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE 'June01,2022 'PERMIT# BLDG-22-006942 "` JOBSITE ADDRESS 17 COPPER BROOK RD I OWNERS NAME MCPADDEN ELLEN M G OWNER ADDRESS 7 COPPER BROOK ROAD SOUTH YARMOUTH MA 02664-4332 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO FIXTURES FLOORS BSM 1 2 3 4 5 6 7 6 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY 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 Ikeith Farnham LICENSE# 11601 SIGNATURE MP©MGF❑JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: 'south shore heating&cooling I ADDRESS. 157 whites path, CITY (south Yarmouth I STATE MA ZIP I02664 I TEL 'S083986901 FAX 'CELL 1 1 EMAIL 1 S310N M3IA32i NY-Id #BI1/12i3d $ :33d El El 11W2i3d 3H1 SV S3A2i3S NOI1VOIlddV SIHI oN saA S310N NOI133dSNI AINO 3Sfl?:10103dSNI 210d 3OVd SIHl S310N NOI103dSNl SVO HOflO I