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HomeMy WebLinkAboutBLDG-21-000155 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lk e ' CITY YARMOUTH MA DATE [July 13,2020 'PERMIT# BLDG-21-000155 JOBSITE ADDRESS 17 AUNT EDITHS RD 1 OWNER'S NAME WILSCHUT ROY G OWNER ADDRESS DRAPER DABNEY AMES 98 CANTERBURY WAY BASKING RIDGE NJ 07920 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO FIXTURES FLOORS-0 " 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 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 1 OTHER DESCRIPTION:fire pit 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 El 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 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC 0# COMPANY NAME: TROY J GILBERT ADDRESS. 39 STATION ST, CITY IWAREHAM I STATE MA ZIP 025711324 TEL FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT El ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY South Yarmouth MA DATE 07/02/2020 1 PERMIT#/3Li i sS JOBSITE ADDRESS 17 Aunt Ediths Road OWNER'S NAME Roy Wilschut OWNER ADDRESS Same TEIl TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [] RESIDENTIAL PRINT CLEARLY NEW: ' RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 1 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 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 Fire Pit 1 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 El 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. � /ll _ PLUMBER-GASFITTER NAME Troy Gilbert 1 LICENSE# 13573 au SIIGGNCjATURE MP MGF JP Ei JGF cJ LPGI Q CORPORATION �# PARTNERSHIP LLC Q# 4350 COMPANY NAME: Coastal Mechanical I ADDRESS 21 L Fruean Ave CITY South Yarmouth 1 STATE MAAiZIP 0 64 JREEIVED 1i08 7 I FAX CELLL508-850-6955 'EMAIL' lisa@coastalphc.com JUL 131070��� BUI ING EPARTMENT By: _ CAS i� Sl d�