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HomeMy WebLinkAboutBLDG-22-001123 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7 CITY YARMOUTH MA DATE August 30,2021 PERMIT# BLDP-22-001123 JOBSITE ADDRESS 12 BISCAYNE AVE OWNER'S NAME BLOOMER AIDAN G OWNER ADDRESS BLOOMER CATHERINE 12 BISCAYNE AVENUE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES 0 NO 0 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 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 1 • 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 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. 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 Michael Mcbride LICENSE# 19681 SIGNATURE MP 0 MGF 0 JP© JGF 0 LPG! 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinper.mcbrideftmail.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 -- MASSACHUSETTS UNIFC7RM APPLICATION FOR A PERMIT TO PEIRFORM GAS FITTING WORK -Zi--- E.- CITY ., L/ / Aid./ MA DATE PERMIT# 22– t(Ze3 JOBSITE ADDRESS/7 65‹.-. 7,,,x.e, , OWNERS NAME44,6040_&422,,N OWNER ADDRESS 77r TEL P -575107 FAX •TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL rg PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:VI PLANS SUBMITTED: YES❑ NO ki APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 t•I 12 1:----3-ttr BOILER BOOSTER CONVERSION BURNER --I COOK STOVE --i DIRECT VENT HEATER I I DRYER FIREPLACE i FRYOLATOR i FURNACE 7 I GENERATOR ' GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN i POOL HEATER • 1 - ROOM(SPACE HEATER 11 ROOF TOP UNIT IIRFOVVF /i) TEST -.. . .. -.. ... iUNIT HEATER (INVENTED ROOM HEATER AUG 2/ 2t21 ' WATER HEATER f OTHER . 3LJILDING Dzi-AR_MEN- 3y -- - - -- ------ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO NO El 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 ❑ 3 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 Pertine t provision of the `✓ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Lo i.r., ,Q a.. PLUMBER-GASFITTER NAME LICENSE#/Not SIGNATURE MP❑ MGF❑ JP 10 JGF❑ LPGI❑ C .PORATION 0# PARTNERSHIP 0# ., LLC❑# OMPANY NAME14 . 0 i�r� ADDRESS 2 t�G►r�c r j 1.1/4to CITY V V P pi f/ STATE ZIP 73 TEL 77W 7/2 FAX CELL EMAI I A ii:k A Al' 01-- •-= L' wir Lion ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONL FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES