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Home My WebLink AboutBLDG-22-005028 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 10,2022 PERMIT# BLDG-22-005028 JOBSITE ADDRESS 97 MAYFLOWER TERR OWNER'S NAME CRAWFORD SIDNIE W G OWNER ADDRESS WHITE DEBORAH 0 925 PIEDMONT RD LINCOLN NE 68510 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 FIXTURES FLOORS-s 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 1 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 1 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 LABILITY 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# 25383 SIGNATURE MP❑MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: (TROY J GILBERT I ADDRESS. 39 STATION ST,39 STATION ST CITY WAREHAM I STATE MA ZIP 025711324 TEL FAX CELL EMAIL kathednetcoastalphc.com S310N M31A321 NVld #IWJ J3d $:333 ❑ ❑ 111A1d3d 3H1 SV S3/12:13S N011v011ddb SIHJ oN saA S310N N01103dSNI lYNId A1N0 3Sf1 H0103dSNI HOd 3OVd SIHL S31ON NOI103dSNI SV0 HOf102I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK S =..tip -" Can; Yarmouth MA. DATE:03/07/2022 PERMIT# Z� " 5o2 ., ,,- JOBSITE ADDRESS: 97 Mayflower Terrace OWNER'S NAME: Sidnie Crawford GOWNER ADDRESS:119 Barn Rd E Stroudsburg , PA 18301 TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ cili PRINT CLEARLY NEW: ❑ RENOVATION:{) REPLACEMENT: 0 PLANS SUBMITTED: YES NOvi _APPLIANCES FLOOR-► Bsmt w 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 1 - , FRYOLATOR FURNACE 1 , GENERATOR b GRILLE INFRARED HEATER A _ _LABORATORY COCK MAKEUP AIR UNIT W S OVEN POOL HEATER A ROOM I SPACE HEATER J ROOF TOP UNIT - TEST 2 UNIT HEATER _ t.,u UNVENTED ROOM HEATER _ WATER HEATER 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Z(NO 0 if you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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,and that my signature on this permit application waives this requirement. i ' ' y9c9-6 CHECK ONE ONLY: OWNER) AGENT ❑ SIGNATURE OF/%WNER 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 all Pertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.Tro �� _ ` PLUMBER/GASFITTER NAME: Y J Gilbert LICENSE# 25383 SI ATURE COMPANY NAME: Coastal Mechanical ADDRESS: 21 L Fruean Ave CITY : S. Yarmouth STATE: MA ZIP: 02664 FAX: TEL: 508-737-8747 CELL: 508-8 0-6955 _ EMAIL: Katherine@Coastalphc.com MASTER ❑ JOURNEYMANO LP INSTALLER ❑ CORPORATION V# 4350 PARTNERSHIP ❑ # LLC [] # E m,/L 11»£-S� , ....` _ _.