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HomeMy WebLinkAboutBLDG-23-001385 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kt-firi___,1 6 CITY YARMOUTH —I MA DATE September 15,202 PERMIT# BLDG-23-001385 JOBSITE ADDRESS 205 WHITE ROCK RD OWNER'S NAME COOPER RYAN M G OWNER ADDRESS COOPER ELAINE R 205 WHITE ROCK RD YARMOUTH PORT MA 02675-2369 TEL TYPE OR OCCJPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El 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❑ 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 pe-mit 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# 11601 SIGNATURE MP© MGF ❑ JP[1 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: south shore heating cooling ADDRESS. 57 whites path, CITY south Yarmouth STATE MA ZIP 02664 TEL 5083986901 FAX —1 CELL EMAIL S310N M31A321 NVId #IIA2l3d $ 33d ❑ ❑ 1IV d 3H1 SV S3ATJ3S NOI1VOIlddV SIHl ON so). S31ON N01103dSNI 1VNH AINO 3Sf1 d0133dSNI NOd 30Vd SIHI S31ON NOLL33dSNI SVO HOfON