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HomeMy WebLinkAboutBldg-22-001057 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ; --: CITY YARMOUTH MA DATE August 24,2021 PERMIT#kt BLDG 22-001057 JOBSITE ADDRESS 37 MIRIAH DR OWNER'S NAME SULLIVAN CHARLES H G OWNER ADDRESS SULLIVAN MILDRED T 37 MIRIAH DRIVE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 ❑ 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 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbride(d),gmail.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 UNIFORM APPLICATION FOR A P RMIT TO PERFORM GAS FITTING WORK ® V ;� CITY 0 MA DATE Z. PERMIT ft W ! JOBSITE ADDRESS 7 /Y , r, 9,ti or , LitOWNERS NAM , . OWNER ADDRESS 47O ZS TEL 3 O `O6 Q0 FAY, 111 i c7YPE)0OR �� OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL g t.a l i. LLl i 'E ;Y NEW:❑ RENOVATION: ❑ REPLACEMENT: V PLANS SUBMITTED: YES❑ NO !. C APPLIA? a FLOORS-4 BSM 1 ? 3 4 5 6 7 8 9 10 'li 12 •13 I- BOILER • BOOSTER CONVERSION BURNER COOK STOVE -- DIRECT VENT HEATER DRYER — '—� FIREPLACE i FRYCiLATOR FURNACE / GENERATOR GRILLE I I INFRARED HEATER --I LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER. ROOF TOP UNIT TEST . . ... ......... .._ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of FIiIGL.Ch.142 YES 0 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 ❑ I • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massarhus-eats General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ J 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 'h Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L PLUMBER-GASFITTER NAME / YO1 LICENSE# SIGNATURE • MP ❑ MGF❑ JP r7t, JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# • LLC❑# COMPANY NAM- (` g pH' ADDRESS 7 2u 5 77 C. 0 r) v—e CITY k- G (sNI- d c.) i- "[ STATED ZIP 0 2—CP 3 TEL / 7 9/Z.Z.- FAX CELL EMAIL i'I -,.0/',0.^1 /`i�CD G�.� ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT(6 PLAN REVIEW NOTES