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HomeMy WebLinkAboutBLDG-21-006492 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 111' gri CITY bRMOUTH MA DATE May 10,2021 PERMIT# BLDG-21-006492 w 1i JOBSITE ADDRESS 11 STUDLEY RD OWNER'S NAME barry davis G OWNER ADDRESS 11 STUDLEY RD SOUTH YARMOUTH MA 02664-4237 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 1 DIRECT VENT HEATER 1 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 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 Michael Mcbride LICENSE# 19681 SIGNATURE MP❑ MGF 0 JP© JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: 'MICHAEL R MCBRIDE ADDRESS. 19 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL ' FAX CELL EMAIL Istinger.mcbride@gmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1- CITY: ot1 . rt 1 M 0 (.4-4// MA. DATE_r/ ,/ PERMIT# !3L-ID6'2t-00(o`T�i2 JOBSITE ADDRESS: l/ 5 Tv n 69,-(7M • OWNER'S NAME /S4' 1 ' )c LI/ s G OWNER ADDRESS: 363 l((k1r(4f45 JUec ��(zpp TEL:?7/, a 7/17f FAx TYPE OR OCCUPANCY TYPE COASIEERCCIIAL rJ r `EE)UCATIONAL 0 RESIDENTWt.0 PRINT CLEARLY NEW:0 RENOVATION:i-`}—REPLACEMENT:g] PLANS SUBMITTED: YES 0 NO 0 APPLIANCESZ FLOOR-0 Bacot 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 _ .. GR Si)� INFRARED HEATER w LABORATORY COCK k MAKEUP AIR UNIT CI OVEN POOL HEATER ROOM/SPACE HEATER J ROOF TOP UNIT TEST UNIT HEATER 14 J (INVENTED ROOM HEATER WATER HEATER _ 'Ivsi-d--° fff15 gtleerl INSURANCE COVERAGE I have a current lability insurance poky or its substantial equivalent which meats the requirements of MGL Ch.142 YES ('EEO 0 If you have checked yo,please Matte the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY r}- OTHER TYPE INDEMNITY 0 SOW 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massada General Laws,and that my signature on this permit application Rejygg this requiremenL 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 enters regarding this application are true and acctrate to the best of my Knowledge and that all plumbing work and installations performed under the per:*issued for INs a wB be In compliance with al Pertinent provision of the State. Code Aend Chapter(42 afthe General Laws. PLU NAME NI MV, > 'rr LICENSE# 9 ��TURE COMPA`NY !^ ,,9_0P H ADDRESS: ? /LC.) 577 C U r i c CITY: k.) C Q i,�j STATE ZEP. 66 6 2(0 3FAx TEL: 1 it 1-0Z?_. CELL: MIL: ..54t r\ cr`,A4c,B r`,c90,4 ,,,-,,L -G"--. MASTER 0 JOURNEYMAN Sg. LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# ✓ LLC 0# E ivtyt.. ADL12e.SS: