Loading...
HomeMy WebLinkAboutBLDG-22-004397 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k4"/ CITY IYARMOUTH I MA DATE (February 08,2022 I PERMIT# BLDG-22-004397 JOBSITE ADDRESS 18 BLUEBERRY PATH VILLAGE OWNER'S NAME DEANGELIS KAREN G OWNER ADDRESS VICHA KEVIN 40 SEAGER FARM RD MARSHFIELD MA 02050 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑ 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 0 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 Famham LICENSE# 11601 SIGNATURE MP©MGF 0 JP❑ JGF❑ LPG( ❑ CORPORATION❑# _I PARTNERSHIP ❑# LLC❑# COMPANY NAME: South Shore Heating 8 Cooling ADDRESS. 57,Whites Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL S3 LON M31A32i NVld #111(12i3d $ :33d ❑ ❑ 111183d 3H1 SV SAS NOI1VOIlddV SIH1 oN s2A S31ON NO1103dSNI 1VNId K1NO 3Sfl 210103dSNI b0d 3OVd SIHI S310N NO1103dSNI SVO Form