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HomeMy WebLinkAboutBLDG-22-000860 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH I MA DATE August 16,2021 PERMIT# BLDG-22-000860 4 JOBSITE ADDRESS 300 BUCK ISLAND RD UNIT 15G OWNER'S NAME PALASZ WALTER J G OWNER ADDRESS C/O DEBRA CONNER 146 POJUNK RD STURBRIDGE MA 01566 TEL 'TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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 COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 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 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 NSURANCE 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# 11601 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: South Shore Heating&Cooling ADDRESS. 57,Whites Path, 1 CITY South Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX —I CELL EMAIL S310N M3IA321 NVId #11Wa3d $:93d ❑ ❑ 111^1b3d 3H1 SV S3Aa3S N011tl01lddV SIH1 oN SaA S31ON NO1103dSNI 1VNld AINO 3Sfl a0103dSNI dOd 39Vd SIH1 S310N NO1103dSNI SVO HOfOd