HomeMy WebLinkAboutBLDG-18-006092 -
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
la CITY west yarmouth IJ MA DATE 3/23/2018 I PERMIT#/ , /8 o'c
JOBSITE ADDRESS 193 camp st building h OWNER'S NAME davenport __.
GOWNER ADDRESS TEL,[7742081977 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL Li
PRINT
CLEARLY NEW:, RENOVATION:[ I REPLACEMENT:L%' PLANS SUBMITTED: YES NO
APPLIANCES-1 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 1
FURNACE 2 — � r
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN •
POOL HEATER
ROOM/SPACE HEATER ,
ROOF TOP UNIT ,,
TEST r
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1r
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets 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
I hereby certify that all of the details and information I have submitted or entered regarding this application are true an curate 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! a dt a 1 Pertine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �—
��til- .X
PLUMBER-GASFITTER NAME[Keith J.Farnham -LICENSE# 11601 SIGNA
MP 7 MGF JP JGF D LPG'® CORPORATION Q# 3698C PARTNERSHIP LJ# LLC #
COMPANY NAME:,South Shore Heating&Cooling,Inc I ADDRESS 57 White's Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX 508-760-2681 CELL EMAIL