HomeMy WebLinkAboutBLDG-20-006141 nn 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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;;L CITY South Yarmouth 1 MA DATE 06/03/2020 PERMIT# ,1P�J" `"�;0�i7
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JOBSITE ADDRESS 71 Raymond Ave IOWNER'S NAME Julie Calvert _
GOWNER ADDRESS 1 Same TEL JFAX1
TYPE OR OCCUPANCY TYPE COMMERCIAL r] EDUCATIONAL D RESIDENTIAL' ]
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CLEARLY' NEW: RENOVATION: i REPLACEMENT: PLANS SUBMITTED: YES 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 Vi;� / _
FRYOLATOR ) /' � ,
FURNACE
GENERATOR
GRILLE �� r
INFRARED HEATER - _. �/
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN 1
POOL HEATER
ROOM/SPACE HEATER :, G ifa.+
ROOF TOP UNIT
TEST f,, __
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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 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 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. l
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PLUMBER-GASFITTER NAME I Troy Gilbert LICENSE# 13573 SIGNATURE
MP i MGF _I JP® JGFQ LPG' CORPORATION'l# PARTNERSHIP #; i LLC, ,#`4350
COMPANY NAME!Coastal Mechanical 'ADDRESS 121 L Fruean Ave
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-737-8747
FAX CELL 508-850-6955 !EMAIL lisa@coastalphc.com 1
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