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HomeMy WebLinkAboutBLDG-23-000101 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .R CITY 'YARMOUTH I MA DATE (July 07,2022 I PERMIT# BLDG-23-000101 JOBSITE ADDRESS 56 PAYSON PATH OWNER'S NAME FAKACH STACIA A G OWNER ADDRESS 56 PAYSON PATH WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 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 I 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY 0 BOND 0 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 famham LICENSE# 11601 SIGNATURE MP©MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: south shore heating&cooling ADDRESS. 57 whites path, CITY s.varmouth STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL I S310N M3IA32i NVld #11W2i3d $ :333 ❑ El ll1,1d3d 3H1 SV S3Ab3S NOI1VOIlddV SIHl oN seA S31ON NOI103dSNl 1VNId NINO 3Sfl 80103dSNI ZiOd 39Vd SIHl S310N NOI103dSNI VD HOIIOH