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HomeMy WebLinkAboutBLDG-23-003874 r • . . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK IL--' CITY IYARMOUTH MA DATE January 17,2023 PERMIT# BLDG-23-003874' RD OWNERS NAME ICOGGESHALL SUSAN J JOBSITE ADDRESS (47 WOOD G OWNER ADDRESS COGGESHALL CHESTER F P 0 BOX 92 118 HAZEN RD CHESTER VT 05143 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:© PLANS SUBMITTED: YES ❑ NO El 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 1 _FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN POOL HEATER ROOM I 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 I LICENSE# 119681 I SIGNATURE MP❑ MGF ❑ JP© JGF 0 LPGI ❑ CORPORATION❑#I 1 PARTNERSHIP ❑#I Inc ❑#I 1 I I9 Rustic Drive, COMPANY NAME: IMICHAEL R MCBRIDE I ADDRESS. I CITY (West Yarmouth I STATE IMA I ZIP 102673 I TEL I I FAX CELL I I EMAIL Istinger.mcbridena.famail.com IVIASSACHUSETTS UNIFORM APPLICATION FOR A ERMIT TO PERFORM GAS FITTING WORK I-rill!: CITY S O 7 a r MA DATE PERMIT#2 '.-3 87 L! JOBSITE ADDRESS 7 1/1%J0 0/�O. 7 DOWNER'S NAMES 1�o" q 4 toX G OWNER ADDRESS_ 1EL • FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[-_14- PRINT CLEARLY NEW:U RENOVATION'.C0 REPLACEMENT:[I PLANS SUBMITTED:YES❑ NO 0 APPUANCES 7. 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 FRYOLRTOR V FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT R r a p OVEN __ POOL HEATER 1. ROOM i SPACE HEATER I JA 13 2023 P d ROOF TOP UNIT TEST i DUI DIN Gtr RTIUi NT UNIT HEATER II "INVENTED ROOM HEATER WATER HEATER OTHER _ESTIMATED VALUE OF WORK: . - Mt i Mimi ill INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ic NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY"INSURANCE POLICY 621 OTHER TYPE INDEMNITY BOND 0 OWNER'S INSURANCE WAIVER:lam 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 0 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 krrowledge and that all plumbing work and Installations performed under the permit issued for this application wilt be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 di /C7/ \ Q 0 • PL UMBER-GASFITTER NAME LICINSE# SIGNATURE MP 0 MGF 0 JP 0 JGF 0 LPG 0 n CORPORATION 0# Pro P PARTNERSHIP 0# C❑# COMPANY NAME i / Cu i r ADDRESS 37 r-a A V../(I 4(/ �NI, / CITY 1 -A-i� /14 I STATE I/A' ZIP d 2J.G,/ TEL 7 7 L w o cl/ Z Z FAX CELL EMAIL IA.1l 1-- /s• Ik c.) r I 4C-e r51 Cp A/411,s(OA&