HomeMy WebLinkAboutBLDG-19-001411 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
. +�=e 7 CITY /m0 MA DATE PERMIT
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JOBSIT ADDRESS I17Z t��I�wr4r.,Qime 012, 1 OWNER'S NAMEC;C ",i,4 ('/4#/e( c,,V
GOWNER ADDRESS )0/440.0to r! t^ _ TELL„),
TYPE OR 'irr!�� _ � �:FAX ,., _�.�w•..._�
PRINT OCCUPANCY TYPE COMMERCIAL S EDUCATIONAL ! I RESIDENTIAL �1
CLEARLY NEW:; ! RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO zip
APPLIANCES Z FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER — `—
J r-
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE i
FRYOLATOR
FURNACE _
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 I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 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
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 acc rate:th of my know dge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc • alyerti pr is' n of t
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f
PLUMBER-GASFITTER NAME Keith J. Farnham LICENSE# 11601 NATURE
MP Fi MGF I JP JGF j LPGI 1 CORPORATION!T#3698C PARTNERSHIP D# LLC j ]# I
COMPANY NAME:[South Shore Heating&Cooling, Inc ADDRESS 57 White's Path
CITY South Yarmouth STATE LMA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL, EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES f2FM/��
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