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HomeMy WebLinkAboutBLDG-22-002759 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1k > z BLDG 22 002759 4e— : CITY YARMOUTH MA DATE November 15,202' PERMIT# JOBSITE ADDRESS 212 BLUE ROCK RD OWNER'S NAME WOODS THOMAS E G OWNER ADDRESS WOODS DOROTHY A 1262 RANDOLPH AVE MILTON MA 02186 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO ❑ 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 1 — 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF 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. 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 LICENSE# 13573 SIGNATURE MP© MGF ❑ JP 0 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: COASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL lisaa(�,coastalphc.com S3ION M3IA32J NVId #LI NH d $:33d ❑ 1IV ]d 3H1 SV SSA213S NOI1V31lddV SIHI oN saA S310N NO1103dSNI IVNId AINO 3Sfl a0103dSNI NOd 30Vd SIHI SALON NO1103dSNl SVO HOf10a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 5'—Ft1s � CITY South Yarmouth MA DATE! 11/10/2021 PERMIT# JOBSITE ADDRESS I212 Blue Rock Road OWNER'S NAME I Tom and Dolly Woods OWNER ADDRESS L62 Randolph Ave-Milton, MA02186 TEII FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL U RESIDENTIAL ._J PRINT CLEARLY' NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES ..] NO APPLIANCES 1 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 1 T GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ • OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER F^ UNVENTED ROOM HEATER WATER HEATER OTHER 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 F13 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. PLUMBER-GASFITTER NAME Tro Gilbert LICENSE# 13573 SIGNATURE MP MGF JP❑ JGF❑ LPG'D CORPORATION J# PARTNERSHIP❑# I LLC C i#i 4350 1 COMPANY NAME: Coastal Mechanical I ADDRESS!21 L Fruean Ave CITY South Yarmouth I STATE MA ZIP 02664 —ITEL 1508-737.8747 FAX CELL 508-850-6955 'EMAIL lisa@coastalphc.corn