HomeMy WebLinkAboutBLDG-18-000233 G-ab 4 50
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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.1f= CITY yarmouthport MA DATE*SOW ii' 7W/001 PERMIT# / G''/$'vim XV
JOBSITE ADDRESS 9 john hall cartway OWNER'S NAME henry traube I
GOWNER ADDRESS , , I TELI 7447239 JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL Lj RESIDENTIAL j
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CLEARLY NEW:❑ RENOVATION:j REPLACEMENT: 'J PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 11-- $ _ I _ j� 'L
BOOSTER
CONVERSION BURNER
COOK STOVE J[
in"
DIRECT VENT HEATER _ II
DRYER
FIREPLACE — __ __-_11-- _I
FRYOLATOR ._ �
FURNACE x ___. L
GENERATOR __ I __
GRILLE I
INFRARED HEATER _ _
LABORATORY COCKS _
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
_UNIT HEATER ' 4L
UNVENTED ROOM HEATER '� 1 it
WATER HEATER _
OTHER j
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— INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 71 I OTHER TYPE INDEMNITY ❑ BOND L.-a
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 nd accu to th f rriy knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn ' e wit all rt' e t rovisio of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �LICENSE# >
PLUMBER-GASFITTER NAME Keith J.Famham 11601 ,/SIGt/��`
NATURE
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MP i 1 MGF __I JP ___y
® JGF❑ LPG!® CORPORATION Q# 3698C PARTNERSHIP❑# LLC 1,_1# _
COMPANY NAME: South Shore Heating&Cooling,Inc I ADDRESS 57 White's Path
CITY South Yarmouth I STATE MA fZIP 02664 _ TEL 508-398-6901 _
FAXI508-760-2681 CELL ,EMAIL
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