HomeMy WebLinkAboutBLDG-22-005855 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r.�. CITY YARMOUTH MA DATE April 13,2022 PERMIT# BLDG-22-005855
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45 JOBSITE ADDRESS 80 TROWBRIDGE PATH OWNER'S NAME FAUCHER STEVEN
G OWNER ADDRESS FAUCHER CATHERINE 80 TROWBRIDGE PATH WEST YARMOUTH MA 02673-3571 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL I=1 RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED:YES El NO 0
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
GENERATOR 1
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 El NO 0
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY El 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 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 (Troy Gilbert I LICENSE# 125383 I SIGNATURE
MP❑MGF El JP El JGF El LPGI❑ CORPORATION 0# PARTNERSHIP 0# LLC❑#
COMPANY NAME: (TROY J GILBERT I ADDRESS. 139 STATION ST.39 STATION ST
CITY IWAREHAM I STATE MA ZIP 025711324 TEL
FAX CELL I IEMAIL Ikatherine! coastalphc.com
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.'" ' CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'` =tl_ 4 ar outh MA. DATE: 04/11 /2022 PERMIT# 1- S 9 CC
SITE .DI•ESS: 80 Trowbridge Path OWNER'S NAME: Catherine & Steven Faucher
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.. DEPA D RR ' SS:80 Trowbridge Path W Yarmouth MA 02673 TEL: 508-737-8747 FAX:
sy: UPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL li
PRINT
CLEARLY NEW:V RENOVATION: 0 REPLACEMENT: 0 PLANS SUBMITTED: YES ❑ NO V
APPLIANCES1. FLOOR-0 Bsmt 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
GENERATOR 1
r GRILLE
V) INFRARED HEATER
VI LABORATORY COCK
MAKEUP AIR UNIT _
OVEN _
POOL HEATER R
tIZ ROOM / SPACE HEATER .
NJ ROOF TOP UNIT t
� TEST
UNIT HEATER 1 _
i isi UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES VNO ❑
if you have checked YES, please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY D 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 ❑
SIGNATURE OF OWNER OR AGENT
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 ail Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: Troy Gilbert LICENSE# 25383 SIGNATURE
COMPANY NAME: Coastal Mechanical ADDRESS: 21 L Fruean Ave
CITY : S Yarmouth STATE: MA ZIP: 02664 FAX:
TEL: 508-737-8747 CELL: 508-850-6955 EMAIL: Katherine(c2Coastalphc.com
MASTER ❑ JOURNEYMAN ❑ LP INSTALLER 0 CORPORATION'# 4350 PARTNERSHIP ❑ # LLC ❑ #
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