HomeMy WebLinkAboutBLDG-19-002102 b • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
''.=:kIF74 CITY South Yarmouth MA DATE 10/01/2018 PERMIT# 4ofr-I q-co o
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JOBSITE ADDRESS 52 Country Club Drive OWNERS NAME Megan Anthony
OWNER ADDRESS Same TEL !FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:ED PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER r j _ r
BOOSTER
CONVERSION BURNER I Ma f_
COOK STOVE _,
DIRECT VENT HEATER _
I
DRYER
FIREPLACE • r_ - -
FRYOLATOR I II _-
FURNACE _
GENERATOR ~I
GRILLE l
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN 1
POOL HEATER 1 11J
ROOM/SPACE HEATER i
ROOF TOP UNIT
TEST
UNIT HEATER i
UNVENTED ROOM HEATER
WATER HEATER 1 I
OTHER
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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 ❑NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑+ 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 ❑ 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 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.
T S.Peach
PLUMBER-GASFITTER NAME Tygue S Reed LICENSE#11(11 Y SIGNATURE.
MP D MGF❑ JP❑ JGF❑ LPG!❑ 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
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