HomeMy WebLinkAboutBLDG-20-002531 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`':=uI1g /�GI� —CITY S.Yarmouth MA DATE 10/23/19 PERMIT#
JOBSITE ADDRESS 13 Mackenzie Rd. OWNER'S NAME Nancy Bryson I George Colina
GOWNER ADDRESS SAME TEL 508-398-6583 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
PRINT —
CLEARLY NEW:I RENOVATION:0 REPLACEMENT: J PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 1 13 14
BOILER ii- 1 � itJ
BOOSTER I___1._
CONVERSION BURNER
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COOK STOVE �I
DIRECT VENT HEATER
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DRYER i' I
bpi FIREPLACE — 1
FRYOLATOR J!---11.--_
FURNACE
GENERATOR r
GRILLE f r I L
INFRARED HEATER _
LABORATORY COCKS _ __
MAKEUP AIR UNIT
OVEN iI 1' — I I
POOL HEATER �
ROOM I SPACE HEATER if _ _it _ !
ROOF TOP UNIT Ir --' 1
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,kz: TEST 1 , F
UNIIT HEATER J N
UNVENTED ROOM HEATER _ --7I
WATER HEATER f
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES j NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
[-- LIABILITY INSURANCE POLICY __ OTHER TYPE INDEMNITY BOND 1-1
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.
CHECK ONE ONLY: WNER ❑ AGENT 0
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 acc at o t st of my wledge —
and that all plumbing work and installations performed under the permit issued for this application will be in comp. e wi all a ne t provis of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
1 PLUMBER-GASFITTER NAME[Keith J.Farnham LICENSE# 11601 SIGNATURE
MP❑ MGF❑ JP 0 JGF L LPGI U CORPORATION Q# 3698C PARTNERSHIP 7 #1 LC❑#
COMPANY NAME: South Shore Heating&Cooling ADDRESS 57 White's Path
CITY South Yarmouth STATE L MA 1 ZIP 02664 TEL 508-398-6901 i
FAXI 508-760-2681 I CELL EMAIL I info@southshoreheatingcooling.com I
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