HomeMy WebLinkAboutBLDG-19-001408 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-N—M CITY west yarmouth MA DATE 08/20/2018 PERMIT# i0b—i Lw I
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JOBSITE ADDRESS 5 glenwood st OWNER'S NAME jean wackrow
GOWNER ADDRESS TEL 7370158 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL? EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:n REPLACEMENT: / PLANS SUBMITTED: YES NO❑
APPLIANCES Z FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER x 11 _ II II ii l! I I
BOOSTER [— —] _
CONVERSION BURNER
COOK STOVE J � � -.4I
DIRECT VENT HEATER _ _ 11--DRYER ll 11-
FIREPLACE I i
FRYOLATOR
FURNACE _ --ir 1,
GENERATOR I;7-11-1F y
GRILLE jJ
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT [ r
OVEN --1 _I —r 1
POOL HEATER I _ IT ,1
ROOM/SPACE HEATER 1 - _t— t
ROOF TOP UNIT r '� '—''
TEST [-_ .1L
UNIT HEATER [ iI-1 j[ _L __ j_ ,
UNVENTED ROOM HEATER
WATER HEATER 1 ,(
OTHER 11- �j —
7 t.
i; J1 It 1,
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 a 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 I I AGENT I
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 a icc r e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli a wi II P rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Famham LICENSE# 11601 SIGNATU E "�—
MP El MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# 3698C PARTNERSHIP❑# LLC❑#
COMPANY NAME: South Shore Heating&Cooling,Inc ADDRESS 57 White's Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL