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HomeMy WebLinkAboutBLDG-22-001124 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK )1"' .4'7 CITY YARMOUTH MA DATE August 30,2021 PERMIT# BLDP-22-001124 t;_ JOBSITE ADDRESS 23 REFLECTION WAY OWNER'S NAME KILROY ROBERT B G OWNER ADDRESS KILROY JOAN M 23 REFLECTION WAY SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL 111 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:1D 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 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 0 OTHER OF INDEMNITY 0 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 (Michael Mcbride LICENSE# 19681 SIGNATURE MP 0 MGF 0 JP© JGF 0 LPG( ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: (MICHAEL R MCBRIDE ADDRESS. 19 Rustic Drive, CITY (West Yarmouth I STATE MA ZIP 02673 TEL FAX CELL EMAIL Isunger.mcbride(a),pmail.com I 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 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ��—_� �{WI ., U�=.r.ro•-N CIT( • — (`AA / W MA DATEZ 5 Z/ PERMIT# JOBSITE ADDRESS 2_, 3 /2 CJ; cgovi k.4.-y OWNERS NAME ru to e i /[`d GOWNER ADDRESS _a__-TEL , 7' 67 FAX ///"` TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL K CLEARLY NEW: RENOVATION: ❑ REPLACEMENT:K PLANS SUBMITTED: YES❑ NO,j APPLIANCES 1 FLOORS—F BSM 1 2 3 4 5 s 7 o 9 10 11 12 13 1 4 1 BOILER BOOSTER CONVERSION BURNER COOK STOVE —1 DIRECT VENT HEATER DRYER ---_1 FIREPLACE 1 FRYOLATOR --I FURNACE GENERATOR. GRILLE I--1 INFRARED HEATER. LABORATORY COCKS I MAKEUP AIR UNIT —H OVEN POOL HEATER ______IE C E ! N E ROOM/SPACE HEATER ROOF TOP UNIT -..�_.7 I TEST _ . . .__ . . . . . . ._ .. ..... UNIT HEATER AUG 2021 UNVENTED ROOM HEATER __ - B IL-DIN; 1-)1=-P4RT WATER HEATER r By.- — 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 42 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. -3CHECK 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 L PLUMBER-GASFITTER NAME LICENSE# 1 / SIGNATURE INP ❑ MCF❑ JP [ JGF❑L 1 ❑ CORPORATION❑# PARTNERSHIP❑Vt Pro ' LLC❑# I� - COMPANY I' (A f ; P 6 ADDRESS 6 /?, v 5/16 0r “Ae CITY VV a CM © U( 1 STATE r "vl- ZIP D Z(p 73 TEL 77( TO g l Z2_ FAX CELL EMAIL at e. . A, :L , .4 s (./' / 616.00 LID ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT i PLAN REVIEW NOTES