HomeMy WebLinkAboutBLDG-19-001472 ! 1,'- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY 'L_.. ...x .MA DATE' I1 l }3 PERMIT# /9AD6.-/?-G'0/ 1 ?
JOBSITE RESSI __1 ]. __1 ,e _4.---- ___ _ __I OWNER'S NAME �0k,tSC l.D !t-e ._Gs-___-
OWNER ADDRESS ' i TEL&DS..� XI .�_Y.I
TYPE OR OCCUPANCY TYPE COMMERCIALrs `ry
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EDUCATIONAL RESIDENTIAL[
CLEARLY NEW: RENOVATION: REPLACEMENT: "e✓� PLANS SUBMITTED: YES , j NOr
APPLIANCES-1 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 I l GENERATOR II
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _
POOL HEATER { R E . E i V ` $
ROOM/SPACE HEATER 1_ t ; : f
ROOF TOP UNIT L
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TEST :r 1._
UNIT HEATER �„Iry=_; 4' Ats t nt- -r --
UNVENTED ROOM HEATER _
WATER HEATER
OTHER I
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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 v NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY v OTHER TYPE 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.
CHECK ONE ONLY: OWNER AGENT
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 comp iance With Pe ��tip�rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,/ - �-4 `.�i
PLUMBER-GASFITTER NAME Keith J.Farnham 6 LICENSE# 11601 Yc�j SIGNATURE
MP /_,I MGF Li JP i JGF IJ LPG!Li CORPORATION #C,&L (. PARTNERSHIP Dill LC L]#[ _
COMPANY NAME: South Shore Heating&Cooling,Inc 3 ADDRESS 57 White's Path
CITY !South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901 'I
FAX:508-760-2681 CELL JEMAILL