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HomeMy WebLinkAboutBLDG-22-006707 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -!.4 'YARMOUTH I MA DATE May 19,2022 PERMIT# BLDG-22-006707 lI JOBSITE ADDRESS 141 HIGHBANK RD OWNER'S NAME HIGHBANK PROPERTIES INC G OWNER ADDRESS CIO BLACK ALEX 141 HIGHBANK RD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ID PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:© PLANS SUBMITTED:YES 0 NO❑ 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 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 ❑ 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# 119681 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: IMICHAEL R MCBRIDE ADDRESS. 19 Rustic Drive, CITY West Yarmouth STATE MA ZIP 102673 TEL I FAX 1 CELL 1 EMAIL Istinger.mcbridena,gmail.com -... ' /V,(4 MASSACH SETTS UNIFORM APPLICATION FOR A PE IT TO PERFORM PLUMBING WORK REt �I C�' 3 6 G(� •� G v ' MA DATE s' PERMIT# 2UZ J SI E ADDRESS 'A ly OWNER'S NAME_ 5 u LLB MAY 0 NE' ADDRESS ���divU l i-Le p/ ( )rEL 5 0 I- 5 3 3 FAX -.-- - MENT A-C_U 5 /�/`J e7— BU D1*'P U 2_ 0 'NCY TYPE COMMERCIAL E] EDUCATIONAL ElRESIDENTIAL 0 CLEARLY NEW:El RENOVATION: REPLACEMENT:51 c1y-7y/,-,s . PLANS SUBMITTED: YES® NO❑ • FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB / _ _ _ y CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM • , DISHWASHER / DRINKING FOUNTAIN FOOD DISPOSER ,-- FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY / 3 _ ROOF DRAIN SHOWER STALL i/'4LI£3o . f" SERVICE/MOP SINK TOILET / 2_ ' URINAL WASHING MACHINE CONNECTION / WATER HEATER ALL TYPES _ WATER PIPING OTHER - /-J/15te 5 .•7--1 cAA ✓ - _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES RI NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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 0 AGENT ❑ Z. SIGNATURE OF OWNER OR AGENT t I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accui ate 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. / q/ PLUMBER'S NAME ('\ is 4e L °' (A �l LICENSE# ( /(0 / SIGNATURE MP❑ JP Q CORPORATION 0# PARTNERSHIP❑.# LLC❑# COMPANY NAME iA (BC ISt- pi-4f .ADDRESS / /('c1 n(/.//I) CITY1--Ai 6( I\ A t 5 STATE 'V vT ZIP 0 7..l0 d I TEL 77 Y 716 �- f FAX CELL EMAIL `j`f- i A 0J ► /Yl c13 1 0 y4,4/e • //,.4.1