HomeMy WebLinkAboutBLDG-17-002873 450
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-'YAW P., CITY yarmouth I MA DATE 11-2-2016 PERMIT#&,V /7-eo,Rpy
JOBSITE ADDRESS 93jefferson ave ]OWNER'S NAME 1. r S'tcc\ kA,Gta(kAlt,Ka. I
GOWNER ADDRESS 136 hombre circle panama city fl 32407 i TEL 508-360-3263 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Erj
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CLEARLY NEW:L.,j RENOVATION:Li REPLACEMENT: Li PLANS SUBMITTED: YES NOD
APPLIANCES Z FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER IIIII MI W r i MIN M MIN
BOOSTER -- 1I--
CONVERSION BURNER ®_ MN
COOK STOVE
DIRECT VENT HEATER
DRYEP.
FIREPLACE NM _
FRYOLATOR ____ JIM
FURNACE
GENERATOR r _ -
GRILLE :11111.—
INFRARED HEATER ____—__=
LABORATORY COCKS iii______
MAKEUP AIR UNIT
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POOL HEATER ®EN 111= �'
ROOM/SPACE HEATER ;' ,
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ROOF TOP UNIT
TEST
UNIT HEATER
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UNVENTED ROOM HEATER
WATER HEATER
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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 ' NO 7
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY f OTHER TYPE INDEMNITY �',I BOND ill
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 tru and a urat tot f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com nce h al i ent provi n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
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PLUMBER-GASFITTER NAME Keith J.Farnham 1 LICENSE# 11601 (., SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPG!0 CORPORATION D# 3698C PARTNERSHIP❑# LLC❑#
COMPANY NAME: South Shore Heating&Cooling, Inc ADDRESS 57 White's Path
CITY LSouth Yarmouth STATE MA IZIP 02664 TEL 508-398-6901
FAX 508-760-2681— CELL EMAIL I
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