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HomeMy WebLinkAboutBLDG-22-004622 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4 F e CITY YARMOUTH _I MA DATE (February 22,20221 PERMIT# BLDG-22-004622 JOBSITE ADDRESS 32 DANAS PATH 1 OWNER'S NAME IZACHER JOSEPH A I G OWNER ADDRESS ZACHER LAURA A 2817 STROHL RD ALLENTOWN PA 18100 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL E PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 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 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 as Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Troy Gilbert LICENSE R 25383 SIGNATURE MP❑MGF❑JP© JGF❑ LPGI ❑ CORPORATION❑#__ PARTNERSHIP ❑# Lc❑# ] COMPANY NAME: TROY J GILBERT ADDRESS. 139 STATION ST,39 STATION ST i CITY WAREHAM STATE MA ZIP 025711324 TEL I FAX CELL I • I EMAIL Ikatherine .coastalohc.com SRION M3IA]H NV-Id #IM L d $ :333 ❑ ❑ IIW2f3d 3H1 SV S3A83S NOI1VOIlddd SIHl oN saA S310N N01103dSNI 1VNId KINO 3Sf1210103dSNI 2103 30Vd SIH1 S310N N01103dSNI SVO HDflO I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,a r, _ CITY: Yarmouth MA. DATE: 02/16/2022 PERMIT# Z2- L.IZ JOBSITE�A�DDpR�ESS: 32 Danas Path OWNER'S NAME: Joe Zacher OWNER ADDRESS: 2AONERLAURAA2817SrRONLROALLENTOWNPA181X TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E/ PRINT CLEARLY NEW:❑ RENOVATION:10 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO E4 APPLIANCES1 FLOOR—, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ CONVERSION BURNER COOK STOVE 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE ti) INFRARED HEATER W LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER .) ROOF TOP UNIT fi TEST .;2 UNIT HEATER r V 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 Ej NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0 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,'� requirement. //and that my signature on this permit application waives this /f/B CHECK ONE ONLY: OWNER E t AGENT ❑ SIGNATU 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 as Pertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. /� te PLUMBER/GASFITTER NAME: Troy J Gilbert LICENSE#25383 Si 1 gnJREQiLt COMPANY NAME: Coastal Mechanical ADDRESS: 21 L Fruean Ave Cry: Yarmouth STATE: MA ZIP: 02664 FAX: TEL: 508-737-8747 CELL: 508-850-6955 EMAIL: Katherine@Coastalphc.com MASTER❑ JOURNEYMAN® LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLcf '# 4350 c h96vc.- ADDizess: