HomeMy WebLinkAboutBLDG-18-006116 • - ' .1,\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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--4-7-41w,i, CITY S. IaPM It ..._._.._.e MA DATE[[VOA PERMIT#-WAb,r"eieUd�r0
JOBSITE ADDRESS I 3 1,�IAslow, frrar R . �OWNER'SNAME Li Kg(y, __V'dlc_,,._...__
GOWNER ADDRESS -O L 6aff S.ym 4 ()Igo/ s To5 37t- 427 if JFAX
TYPE OR —
PRINT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL 0 RESIDENTIAL El
CLEARLY NEW:L,_-1 RENOVATION:n REPLACEMENT: PLANS SUBMITTED: YES 7 NOL✓'
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 I 6 7 8 9 10 11 12 13 14
BOILER _ _ —.
BOOSTER
Li—
CONVERSION BURNER jr I __ =
COOK STOVE 1. .__
DIRECT VENT HEATER r h �_ _ 1
DRYER �^ _ -I[—
i,
FIREPLACE I _ �f1_`� —ljf_ �I 1f =
FRYOLATOR ii _
.'Sq#FURNACE i l IL
GENERATOR 1.. ('
GRILLE r —1_ I _ —.PI
INFRARED HEATER � I 1
LABORATORY COCKS ... -I__._.__�IJ- 1 7I Il
MAKEUP AIR UNIT !! J
OVEN ._ - ;� j I'
_.
POOL HEATER _ j_
ROOM 1 SPACE HEATER -i l
ROOF TOP UNIT — �) Jr--
TEST
UNIT HEATER _ —.
UNVENTED ROOM HEATER
Z WATER HEATER / -I_
OTHER
I
INSURANCE COVERAGE _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO n
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1=1 OTHER TYPE INDEMNITY I BOND n
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 L-_' AGENT 17
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 ac utat t of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli e w' I ertinent p sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Keith J.Farnham LICENSE#1 11601 SIGNATURE
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MP(_v MGF n JP 0 JGF D LPGI CORPORATION # 3698C PARTNERSHIP Q# LLC Ej#
COMPANY NAME: South Shore Heating&Cooling, Inc ADDRESS 57 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-398-6901
FAX ,508-760_2681 CELL ,EMAIL