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HomeMy WebLinkAboutBLDG-22-003574 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 28,202'PERMIT# BLDG-22-003574 6, 7` ' JOBSITE ADDRESS 15 GLENWOOD ST OWNER'S NAME OFFICER JOHN DAVID G OWNER ADDRESS WADE MARCIA J 60 SUTTON PLACE SOUTH NEW YORK NY 10021-4168 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY© OTHER OF INDEMNITY El BOND El 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 A 11601 SIGNATURE MP❑MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: SouthShore Heating&Cooling ADDRESS. 57,Whites Path.Whites Path,Whites Path,Whites Path, CITY South Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX CELL EMAIL S3ION M3IA32J Ndld #111A1213d $ :33d El ❑ 1111213d 3H1 SV S3AN3S NOI1` OIlddV SIHI oN saA S310N NOI103dSNI 1VNIJ AlNO 3Sl 210103dSNI HOd 3OVd SIHl S310N NO1103dSNI SVO HOf102i