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HomeMy WebLinkAboutBLDG-22-005671 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE April 05,2022 PERMIT# BLDG-22-005671 JOBSITE ADDRESS 19 BUNTING LN OWNER'S NAME Timothy Burgess G OWNER ADDRESS 01562 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ED PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 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 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 0 OTHER OF INDEMNITY❑ BOND 0 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 ❑ JP© JGF❑ LPG! 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: TROY J GILBERT ADDRESS. 39 STATION ST,39 STATION ST CITY WAREHAM STATE MA ZIP 025711324 TEL FAX CELL EMAIL katherineacoastalphc.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETIS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r.I CITY: Yarmouth MA. DATE: 04/01/2022 PERMIT# 2 JOBSITE ADDRESS: 19 Bunting Lane OWNER'S NAME: Timothy Burgess G oWNERADDRESS:721 Lenox St Athol MA 01331 TEL: 978-407-1157 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IV PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO[Y APPLIANCES. FLOOR Bsmt 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 1 GENERATOR GRILLE V} INFRARED HEATER LABORATORY COCK _ MAKEUP AIR UNIT OVEN POOL HEATER _ ROOM/SPACE HEATER `} ROOF TOP UNIT TEST _ _ UNIT HEATER 14,1 UNVENTED ROOM HEATER WATER HEATER 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 have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT 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. /� _ de PLUMBER/GASFITTERNAME: Trny .1 (�iIhArt LICENSE# 25383 /NATURE COMPANY NAME: Coastal Mechanical ADDRESS: 21 L Fruean Ave CITY: Yarmouth STATE: MA ZIP: 02664 FAX: TEL: 508-737-8747 CELL: 508-850-6955 EMAIL: Katherine@Coastalphc.com MASTER 0 JOURNEYMAN❑ LP INSTALLER❑ CORPORATION V# 4350 PARTNERSHIP 0# LLC❑# C 4i1. ADLZrzess