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HomeMy WebLinkAboutBLDG-22-000887 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK git CITY [ARMOUTH _I MA DATE August 17,2021 PERMIT# BLDG-22-000887 JOBSITE ADDRESS 23 WINSOME RD OWNER'S NAME POST STEVEN C G OWNER ADDRESS POST TRACY A 23 WINSOME ROAD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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 p DIRECT VENT HEATER DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I l 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❑ 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 State Plumbing Code and Chapter 142 of the Geieral Laws. PLUMBER-GASFITTER NAME Troy Gilbert LICENSE# 13573 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: [COASTAL MECHANICAL ADDRESS. 21 L Fruean Ave, CITY WAREHAM STATE MA ZIP 025711324 TEL FAX I 1 CELL EMAIL lisa(a coastalohc.com S310N M3IA321 NVId # $:33d ❑ ❑ 11W213d 3H1 SV S3Aa3S NOIIVOIlddV SIHl oN safe S31ON NO1133dSNI 1VNId KINO 3Sf1 a0103dSNI 210d 30Vd SIHI S310N NO1103dSNI SVD HOfOa MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY South Yarmouth MA DATE 08/16/2021 PERMIT # JOBS TE ADDRESS 23 Winsome Road OWNER S NAME Steven and Tracy Post OWNER ADDRESS Same TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ri RESIDENTIAL El PRINT CLEARLY NEW: / RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS—. SSh9 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 1 TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current IiabiliLinsurance 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 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 ssued 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 TroyGilbert LICENSE # 13573 SIGNATURE MP MGF JP 1 JGF D LPGI LJ CORPORATION # PARTNERSHIP E # sy.__...... LLC # 4350 COMPANY NAME: coastal Mechanical ADDRESS 21 L Fruean Ave , CITY South Yarmouth I STATE MA ZIP I 02664 TEL I508-737-8747 FAX CELL 508-850-6955 EMAIL iisa@coastalphc.com