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HomeMy WebLinkAboutBldg-21-001418 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 ` CITY YARMOUTH MA DATE September 18,202 PERMIT# BLDG 21 001418 kr, L 1,-,- � JOBSITE ADDRESS 769 ROUTE 28 OWNER'S NAME YARMOUTH LODGE 2270 LOYAL ORDR MOOS G OWNER ADDRESS P 0 BOX 186 SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL Q RESIDENTIAL 0 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 , GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER , ROOM I SPACE HEATER ROOF TOP UNIT TEST 1 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❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbridefigmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No j�c j Ok. G FS wiri nd THIS APPLICATION SERVES AS THE PERMIT ID GI FEE: $ PERMIT# PLAN REVIEW NOTES g;, ,,, r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMI TO PERFORM GAS FITTING WORK n CITY - Q 4 �n1eV MA DATE __ --__ PERMIT G a1-- f w /�lq JOBSITE ADDRESS`9� 4 t�i ST I Z(�(J _ OWNER'S NAME 6 0 se--to�j�,e 1 GOWNER ADDRESS ; TEL r TFAX ---- TYPE OR OCCUPANCY TYPE COMMERCIAL, EDUCATIONAL _J RESIDENTIAL'J, PRINT CLEARLY NEW:,J RENOVATION:J REPLACEMENT:;_I PLANS SUBMITTED: YES J. NOild APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ___1_.!:____1__I__J.__I_—J__1 _J _1 I_J__I BOOSTER I I I 1 Tt. J—J_____I___1 .� I—J I—_1 CONVERSION BURNER I I:_ I I___J 1 I.__J I F'__1:_}__I COOK STOVE _1._J_1 I__1 I___I:_—I__I— —J J_J —J DIRECT VENT HEATER I —J; I ' _l__J I 1—J I I_J DRYER• I_ .. __ I . .I-1_______I_ _ ._ _.I_ .__I I I_. _ I_I FIREPLACE I I____I___J__J J..._.J 1 ._ I __J _ . I ._ I_J. J—1 FRYOLATOR _._.I -I._J,_1._I —J__I __.I I ! _ ._l —J__I_—_1,1 JFURNACE I I___._I_J__.__1—I 1 I ____1 , __—' -__l ..__I I GENERATOR 1 I I I I._ _..._.I i_ �!_-1____J___I__J—J GRILLE I f.__1 I i I._J____1__I_ _I __I _____J. -.J__-._.I____J INFRARED HEATER I—J__I __I 1 ! I I :____I—J _J !_1 1 LABORATORY COCKS I 1.._._._i__.__J._._J`J I__._J__..__I__._J____J __I__.1___._I__J MAKEUP AIR UNIT I I_ I__1__J___I_J __.._I I—1_J___I_1 OVEN t POOL HEATER ' I I�s_. I__I__I_.._...I___II_._J J__..a;____I_____I_____1_J ROOM/SPACE HEATER __! ROOF TOP UNIT ...I r ! I r ! _i I_I _ 11- -! TEST _1 / - i I_ I_I !__I _I_ i I i_1 I UNIT HEATER � UNVENTED ROOM HEATER __I_J I �__-. 1__I i____�_j__I I+_,_„_,i___J WATER HEATER _ �J I i i .. I i_____1_J 1 r__J�J OTHER I i_�i. I, i.. i I_-___I- I I _J_�J_ -J._ I • I I I I _._I _ I_____i___J I I__I _ .__ __I _J yob I_._J_ _ I_ _J - I `----I-J !.__-__i_ —I I____I i i 1 I !. _J I..___I _! J -I I �' . _ I INSURANCE COVERAGE _ tI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES { NO .J. I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -4k. OTHER TYPE INDEMNITY 'J BOND lJ 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 -_I 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME tita3e.--,4 ;r - G1 • I LICENSE#11tliti -CL" If?iGNATUR MP __I MGF_J JP JGF j LPG' _J CORPORATION_I#'IP;_ _PARTNERSHIP Li# I LLC _[#` COMPANY NAM : ' I ADDRESS _ 4 -- ..__' 1 U 10 c 0 d" , I - - f CITY .G� r�'`,f� _... .I STATE . . ZIP .._ _ ._ �TEL , FAX _._._ ...__....___ CELL. EMAIL GJ4tr e . c.,6 r 1 a' 1 .1 4' ' .( 4)111 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES T� Si Odle 9'//k/202e1 c� Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE: $ PERMIT# PLAN REVIEW NOTES �W -