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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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•9a,i— CITY r Yarmouth MA DATE 11/202017 PERMIT#� &47-odA.%g
JOBSITE ADDRESS Green Way _
44 OWNER'S NAME[Burnett G • • .�..
OWNERADDRESS J TEli 1FAX`w ��
TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL f1 RESIDENTIAL I N
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CLEARLY NEW:[ RENOVATION:1).d REPLACEMENT:[-_..] PLANS SUBMITTED: YESO NOR
APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —1 I. i 1 k 1,._.. Vim... -'r '
BOOSTER ',„:,_1...,,..--,_!El,_ . 1_:7,.. .,, , I ( ....-.. ., .-(I
CONVERSION BURNER l; 1 I I _ r h if. l Ir
COOK STOVE „„:„,if: i I _ 1 I 1
DIRECT VENT HEATER [ r�.�- 1._.,, C I, -)I :-I i �:,k.l .. I
DRYER _— — r
FIREPLACE
FRYOLATOR
FURNACE } 4, r I j.
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GENERATOR I----I' —
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GRILLE I I. • „� 1i f• { [I ,�a
INFRARED HEATER Ir i. • I.,.. 1 r--.7„.--1-Jf., r (, I I r
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LABORATORY COCKS I — �_
MAKEUP AIR UNIT 'I- i (- f Er- '- .. +
OVEN 1 .1 11 1 II i( Ir 11 ( -1
POOL HEATER II_ l [ I 1 I
ROOM/SPACE HEATER ...._�__ _I r_ _. r .f I, , : 1 ;.,-)1 - t.., ....I„ , -' ._ I( i . ... .1
ROOF TOP UNIT _— ll I.: 1. 1_-LIz ,._,_ff(- 1 _ I. ,. ...IL . ....:.I._ �-
TEST - li I .._ ��.� . I, f 1 ! s ,
UNIT HEATER q
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UNVENTED ROOM HEATER - .,.. ,1rs, _,,. , _1i_.... '.._. _ ___ ..11_ (:_-. _.1... _. !I I .. __
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WATER HEATER ___
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OTHER ..... .1
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [X-,] OTHER TYPE INDEMNITY L] BOND Li
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. I
CHECK ONE ONLY: OWNER [.1 AGENT [» 1
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 vi, :II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4
PLUMBER•GASFITTER NAME r Tygue Reed LICENSE#I, 15200 J (fir ATURE
MP FA MGF 0 JP Li JGF❑ LPG!® CORPORATION rj#`.Y_ry_ PARTNERSHIP[i# LLC # 4047C 1
COMPANY NAME: Coastal Plumbing,Heating and Cooling
�1 ADDRESS[ 299 Whites Path
CITY I South Yarmouth STATE MA J ZIP 02664 ]TEL 1 508-737-8747 d
FAX CELLI 508 246 9959 1EMAILLtygue@coastalph com ,__ ,_ ,�,_�,_,
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