HomeMy WebLinkAboutBLDG-21-001558 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
11 CITY YARMOUTH MA DATE September 25,202 PERMIT# BLDG-21-001558
JOBSITE ADDRESS 9 LOCH RANNOCH WAY OWNER'S NAME GILLIGAN DIANNE 0
G OWNER ADDRESS 9 LOCH RANNOCH WAY YARMOUTH PORT MA 02675 TEL
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 1
BOOSTER
CONVERSION BURNER
COOK STOVE
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❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSJRANCE POLICY ❑ OTHER OF INDEMNITY III 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 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: E;OASTAL MECHANICAL ADDRESS. 21 L Fruean Ave,
CITY WAREHAM STATE MA ZIP 025711324 TEL
FAX 1 CELL EMAIL lisa@coastalphc.com
Imo, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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GTY Yarmouth Port MA DATE 09/16/2020 , _ I PERMIT # BUil- 55 '
_, -
JOBSITE ADDRESS 9 Loch Rannoch Way _ _..,... OWNER'S NAME I Leda Knight
GOWNER ADDRESS Same TEL IFAX' j
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ,, - �_ ��
BOOSTERL .
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER it.,.,. ,
FIREPLACE -
FRYOLATOR r
FURNACE ' _, _ .�
GENERATOR
_ ,___ — — ---"""1"H"i"...1"---"1-0
GRILLE . �_I,�.. .� t
INFRARED HEATER . �,�,,,._I
a, 1
oft:
LABORATORY COCKS ....._,
MAKEUP AIR UNIT L ___ _ _ __I....IL _ _
OVEN
POOL HEATER
ROOM J SPACE HEATER —.
ROOF TOP UNIT ii i _ _.. _._ is _._ . ..
r1
TEST
UNIT HEATER I
UNVENTED ROOM HEATER I
WATER HEATER W-. J _- . .
OTHER.. ........ -
; .:
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO I
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i 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 cr 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 I ATUR
MP MGF j JP JGF J LPGI L. CORPORATION # PARTNERSHIP L L C a#I 4350
COMPANY NAME: Coastal Mechanical ADDRESS 21 L Fruean Ave
CITY South Yarmouth STATE MA I ZIP 02664 TEL 508-737-8747
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FAX 1 CELL[508-850-6955 , EMAIL[Iisa@coastalphc.com