HomeMy WebLinkAboutG-19-2946 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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;,mylilE.7 CITY South Yarmouth MA DATE 11/8/2018 PERMIT44,06-19-00/901
JOBSITE ADDRESS 59 North Dennis Road OWNER'S NAME Michael Mallor
G OWNER ADDRESS same TEL IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW:Q RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
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BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
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FURNACE
GENERATOR 1 C__,
GRILLE �i —
INFRARED HEATER
LABORATORY COCKS ,
MAKEUP AIR UNIT
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POOL HEATER
ROOM/SPACE HEATER I _ I __I _ _„ J 0 I
ROOF TOP UNIT I 11;
TEST _ _ _ _ _
UNIT HEATER . . '/13Th
UNVENTED ROOM HEATER I
WATER HEATER •:_I'ii n�r,;:RF,;ARTL=NT
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 Q 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. n
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PLUMBER-GASFITTER NAME Tygue S Reed LICENSE# 15200 r SIGNATURE
MP Q MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION D# 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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