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HomeMy WebLinkAboutBLDG-22-003217 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH1 MA DATE December 07,202'.PERMIT# BLDG-22-003217 JOBSITE ADDRESS 161 MATTAKESE RD I OWNER'S NAME 'Jeff Dietz G OWNER ADDRESS 61 MATTAKESE RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:0 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 I 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 0 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 Slate Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 'Troy Gilbert 1 LICENSE# 113573 I SIGNATURE MP©MGF❑JP 0 JGF 0 LPGI ❑ CORPORATION❑#1 1 PARTNERSHIP ❑#1 ILLC❑#I 1 COMPANY NAME 'COASTAL MECHANICAL 1 ADDRESS. 121 L Fruean Ave. CITY 'WAREHAM 'STATE MA ZIP 1025711324 I TEL I FAX I I CELL I I EMAIL Ilisa ancoastalphc.com 1 S31ON M3U13b NYld #11M13d $:333 ❑ ❑ 1I1183d 3H1 SV S3A213S NOI1VDIlddV SIHl oN saA S310N NOI.133dSNI lYNId AlNO 3Sf1210133dSNI?JOd 3OVd SIHl S31ON NO1103dSNl SYD HDflO r` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _� i= >� =vim - CITY Yarmouth l MA DATE 12/0112021— PERMIT # L t - 31 l 1 _ JOBSITE ADDRESS 61 Mattakese Road - - OWNER'S NAME 1 Jeff Dietz OWNER ADDRESS 10 Orchard Park Drive - Reading, MA 01867 TEL IFAX TYPEP OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL RINT CLEARLY NEW:ri RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO APPLIANCES -1 FLOORS-i BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER ---- r CONVERSION BURNER ► ---- COOK STOVE DIRECT VENT HEATER - --- DRYER FIREPLACE :: . F RYO LATO R -- — 1 FURNACE 1 _ GENERATOR GRILLE INFRARED HEATER _LABORATORY COCKS 1 - - .: MAKEUP AIR UNIT I let -OVEN u. POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT 104 ri. TEST UNIT HEATER :_. UNVENTED ROOM HEATER WATER HEATERJimm OTHER - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 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 L' AGENT Q 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. '`'—/20"ff ydev,t--- PLUMBER-GASFITTER NAME Troy Gilbert LICENSE # 13573 GNATURE MP MGF JP Q JGF El LPGI Q CORPORATION , #L.-... PARTNERSHIP 8 _e#[ l LLC 0#1 4350 1 COMPANY NAME: Coastal Mechanical ADDRESS[21 L Fruean Ave CITY South Yarmouth - 4 STATE MA 1 ZIP i 026641TEL 1508-737-8747 FAX 1, 1 CELL 508-850-6955 EMAIL Iisa a@coastalphc-com