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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
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CITY ! MA DATE Jip _ . PERMIT# / 4- - /la-0V /9'O
JOBSITE ADDRESS_`iC� l f I iL(__ci_y k
G O OWNER'S NAME , VA�jV� �� J
WNER ADDRESS I. I I�l c Q 1 v
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL
PRINT RESIDENTIAL
CLEARLY NEW: RENOVATION: REPLACEMENT:!'
PLANS SUBMITTED: YES NO[
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER t t7yv k;t\tk\; r
BOOSTER ,
CONVERSION BURNER _
COOK STOVE �:
DIRECT VENT HEATER --
DRYER
FIREPLACE _
FRYOLATOR
FURNACE '
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT -
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_tee:
TEST
UNIT HEATER _
UNVENTED ROOM HEATER ' ,
WATER HEATER
OTHER
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INSURANCE
ERAGE
I have a current liability insurance policy or its substantial equivalent which Vmee s 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 r..
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 lance ith I Pe . t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4aer,/
PLUMBER-GASFITTER NAME IT-Keith J.Farnham '` " GNAT _G
LICENSE# 11601
� -�- � � SIGNATURE
MP MGF JP(" JGF LPGI CORPORATION[ # �C r fl
�(s ( �- PARTNERSHIP # �' LLC #
COMPANY NAME:1 South Shore Heating&Coolin llnc ADDRESS]57 White's Path
CITY ?South Yarmouth
STATE MA J ZIP]02664 aTEL 1 508-398-6901 I
_"n_ ..r Ha-
FAX1.50760-2681 CELL EMAIL
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
ROUGH GAS INSPECTION NOTES Yes No �� ar,/ B v p 0
( THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ I2 U CO
-_ 1111111%
FEE: $ PERMIT#
PLAN REVIEW NOTES
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