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HomeMy WebLinkAboutBLDP-22-000851 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r' c CITY YARMOUTH MA DATE August 16,2021 PERMIT# BLDP-22-000851 lr JOBSITE ADDRESS 86 WIMBLEDON DR OWNER'S NAME MORAN ELAINE G OWNER ADDRESS 4 WHIFFLETREE RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 FIXTURES FLOORS—I 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 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 I SIGNATURE MP 0 MGF 0 JP© JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: (MICHAEL R MCBRIDE I ADDRESS. 19 Rustic Drive, CITY (West Yarmouth 'STATE IMA I ZIP 102673 I TEL 1 FAX 1 1 CELL 1 1 EMAIL Istinger.mcbride(a amail.com S310N MIA NVld #111%13d $:33d ❑ 0 IJ11a3d 3H1SV S3AH3S NOIlVOIlddV SIHl oN seA S310N NOI103dSNI IVNId NINO 3Sf1210103dSNI 210d 3OVd SIHI S310N NOI103dSNI SV)HOf O I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO PERFORM GAS FITTING WORK .7 CITY CA—,--\1� f M D V t---11MADA I Zl PERMIT# ZZ S'2C JOBSITE ADDRESS '.S CD Z Il_( At bL. OWNER'S NAME -C9C 'S U U l UR/9 GOWNER ADDRESS bk—,4( P- -e 7 /44.- 7- it ,77- �l f ZFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 7 FLOORS-4 9SM 1 2 3 _ 4 5 6 7 8 9 10 11 12 1;----T _ 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE . DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - P1 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN ,ray 13 021 POOL HEATER . ROOM/SPACE HEATER --- ROOF TOP UNIT Buba niNio 1)1--HtiRTIMPNT TEST _.. ... ... . .__. . . . . . . ._ ....__.._.._ .. . ......._ .._ UNIT HEATER INVENTED ROOM HEATER - WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El 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 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 A � � PLUMBER-GASFITTER NAMEPO- L(J J Cst t.��&eL LICENSE# SIGNATURE UR MP❑ MGF❑ JP j;;1 JGF❑ LPG'❑ CORPORATION El# PARTNERSHIP 1:1# LC ED# COMPANY NAME C 1(7--ta t T ADDRESS vvv/ 5r7 C 4 r( (le CITY `--^1 >----{G\ Cik40 U ' "l STATE 1/141V—` ZIP 0 2 ! 3 TEL ?7 r7 d Y/�z FAX CELL EMAIL'S —uA f/`-44 9-P @))A"414- `c-lis-\. 4 ROUGH GAS INSPECTION NOTES IBIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES