HomeMy WebLinkAboutBLDG-19-000961 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
et
?t"k(_i. CITY South Yarmouth MA DATE 08/17/2018 PERMIT# earhaa-4996/
JOBSITE ADDRESS 16 Eldridge Road OWNER'S NAME Fred Sieland
OWNER ADDRESS 184 Mountain Road-Pleasantville,NY 10570 TEL 1FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIALQ
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:a PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1. FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10i 11 12 13 14
BOILER
BOOSTER - - - -- - - - - - -
CONVERSION BURNER
COOK STOVE -� - -
DIRECT VENT HEATER
DRYER - !I _ . ii . _ll_ i „ - .�....I, i .i- _ - a i -.
FIREPLACE ~ - - -
FRYOLATOR its
FURNACE 1111 i 1' . .0!
__-
GENERATOR 1 .__
GRILLE ! ~��
INFRARED HEATER i i,r T Ill'I_--
LABORATORY COCKS i � I
MAKEUP AIR UNIT i`JC I
OVEN I L!3 c i I
ROOM HEATER fi L -_� .1
ROOM - ..
ROOM/SPACE HEATER - ' -
ROOF TOP UNIT -' -
TEST 1 - "-- - - -
UNIT HEATER -. i o
UNVENTED ROOM HEATER 1
WATER HEATER "� - _.i -- - -
OTHER _.
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 Q OTHER TYPE 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
CHECK ONE ONLY: OWNER 0 AGENT o
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. V`ezt 51
,442
PLUMBER-GASFITTER NAME Tygue S Reed LICENSE# 15200 SIGNATURE
MP 0 MGF❑ JP® JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑#- LLC Q# 4047C
COMPANY NAME: Coastal Mechanical ADDRESS 299 Whites Path
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-737-8747
FAX 508-760-5800 CELL 508-246-9959 EMAIL lisa@coastalphc.com
4_5
a 14- ?A ilic