HomeMy WebLinkAboutBLDG-20-006415 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
?Lta CITY(Yarmouth I MA DATE 06/24/2020 PERMIT#/ eYrwtwe 11
JOBSITE ADDRESS 37 Moss Road _._ OWNER'S NAME Derek Johnson
GOWNER ADDRESS 5 Berg Court East-Middletown,NJ 07748 'TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW:J RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR 1
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 I
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 AGENT', I
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. n, _
/2B L
PLUMBER-GASFITTER NAME,Troy Gilbert LICENSE# 1 5573 c((/SIGNATURE
MP MGF❑ JP❑ JGF L LPGI`] CORPORATION ;# "—I PARTNERSHIP❑#! I LLC 4350
COMPANY NAME:Coastal Mechanical I ADDRESS!21 L Fruean Ave
CITY South Yarmouth STATE MA ZIP 02664 lTEL1508-737-8747
FAX CELL 508-850-6955 EMAIL lira@coastalphc.com
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