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HomeMy WebLinkAboutBLDG-22-002362 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK . BLDG 22 002362 ,kre� CITY YARMOUTH MA DATE October 25,2021 PERMIT# tI-- JOBSITE ADDRESS 126 SEAVIEW AVE OWNER'S NAME KILEY LUANNE M G OWNER ADDRESS BARNEY DOUGLAS D 84 BEAL ST LUNENBURG MA 01462-1320 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ CONVERSION BURNER 1. COOK STOVE - DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 - - - GENERATOR GRILLE - INFRARED HEATER - LABORATORY COCKS - - MAKEUP AIR UNIT i • OVEN POOL HEATER • ROOM/SPACE HEATER . ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER - - - WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Keith Farnham LICENSE# MA SIGNATURE MP© MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: SouthShore Heating&Cooling ADDRESS. 57,Whites Path,Whites Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL S310N MIA NVId #11WH3d $:33d 11WN3d 3H1 SV S3A213S NOI LVOIlddV SIHI oN saA S31ON NO1103dSNI IVNId AINO 3Sfl 2J0103dSNI HOd 30Vd SIH L S310N N01103dSNI SVO HJl0?J