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HomeMy WebLinkAboutBLDG-22-002627 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY YARMOUTH MA DATE November 08,202'PERMIT# BLDG-22-002627 1.,- --f JOBSITE ADDRESS 28 COTTAGE DR OWNER'S NAME MCGAHEY SHERRY L G OWNER ADDRESS 28 COTTAGE DR WEST YARMOUTH MA 02673-3514 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ 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/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❑ 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# LMA SIGNATURE MP 0 MGF 0 JP❑ JGF 0 LPGI ❑ CORPORATION❑# PARTNERSHIP ❑h LLC❑# COMPANY NAME: SouthShore Heating&Coolino ADDRESS. 57,Whites Path,Whites Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL S310N M31Aa1 NVld #llWb3d $ :33d ❑ ❑ 11M3c1 31-11 SY S3AH3S NOI1VOIlddV SIHI oN SOA S310N NOI103dSNI 1VNI3 AlN0 3Sf H0103dSNI 210d 3OVd SIH! S310N NOI103dSNI S O HJl0H