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HomeMy WebLinkAboutBLDG-23-001788 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE October 04,2022 PERMIT# BLDG-23-001788 I, JOBSITE ADDRESS 60 BROADWAY UNIT 9 OWNER'S NAME THE TIME SHARE ESTATE TRUST G OWNER ADDRESS 1 ARDELL RD BRONXVILLE NY 10708 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL ED PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0 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/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 0 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# 19681 SIGNATURE MP 0 MGF ❑ JP© JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: 'MICHAEL R MCBRIDE ADDRESS. 19 Rustic Drive, CITY 'West Yarmouth I STATE MA ZIP 02673 TEL FAX 1 CELL ' EMAIL stinger.mcbride(a,pmail.com Pid ' MASSACHUSETTS UNIFORM APPLICATION FOR APE MIT O PERFORM GAS FITTING WORK `"sjCITY MA DATE n ,� � i✓ PERMIT# JOBSITE ADDRESS / ._ /7i 7 ta Q „ ,r�d� G L ' tMVER'S NAME GMER ADDRESS 40 e r(9Ct ev..4-7/ S 1 - kfi_ 77/176 6TYPE COB / FAX TYPE COMMERCIAL❑ EDUCATIONAL [ E- d`�1 CLEARLYR�SIDENTI NEW:❑ RENOVATION: ❑ REPLACEMENT:[ PLANS SUBMITTED: YES 0 NO APPLIANCES 7. FLOORS-4 BSM 1 2 3 1 5 6 7 g BOILER 9 10 11 12 13 11 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS R E C E 1 E ES —'-1 MAKEUP AIR UNIT OVEN _ POOL HEATER ROOM I SPACE HEATER OCT• E 2Q 2 ROOF TOP UNIT TEST o, . T. .__ __-----_____-- UNIT HEATER _ .._... all UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liabiii insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [S NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 0 LIABILITY INSURANCE POLICY [ OTHER TYPE 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 CHECK ONE ONLY: OWNER 0 AGENT El 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 Li") 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. p6 \ /� PLUMBER-GASFITTER NAME 1 � . LICENSE# aAJRE` - -'�1-- MP❑ MGF 0 JP iiiJ JGF 0 LPGI D �,JCORPORATION❑# - PARTNERSHIP 0 tt LLC 0# COMPANY NAME S 4 ADDRESS )7 FqiiL %i ili ,j /V CITY _ d STATE ZIP U 2 ( e / TEL 7 7 V 7/� fizz FAX CELL EMAIL et., nr , CIC*N I