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HomeMy WebLinkAboutBLDG-23-002711 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK M c' CITY 'YARMOUTH c I MA DATE (November 15,2024PERMIT# BLDG-23-002711 JOBSITE ADDRESS 121 CHASE GARDEN LN I OWNER'S NAME (HART KEVIN F G OWNER ADDRESS (HART CLAIRE M 21 CHASE GARDEN LN YARMOUTH PORT MA 02664 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL ID 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 1 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 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 MP 0 MGF El JP© JGF❑ LPGI ❑ CORPORATIONL❑#SE� PARTNERSHIPSIGNATURE COMPANY NAME: MICHAEL R MCBRIDE 0#�LLC ❑#� ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAxMM. CELL EMAIL stinger.mcbrideftmail.com i� _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT -C PERFORM GAS FITTING `•'��'o JN, WORK�..- •_' CITY / '-, .: ./ . rl. I MA DATE Z� JGBSITE ADDRESS PERMIT# `' f Lel OWNER'S NAME / c .— G ADDRESS TYPE OR GC TEL OCCUPANCY FAY, I'Ftlhl� Y TYPE COMMERCIALEDUCATIONAL CLEARLY ❑ ❑ RESIDENTIAL NEW:❑ RENOVATION: ❑ REPLACEMENT: V PLANS SUBMITTED: YES 0 NOX BOILERAPPLIANCES 1 FLOORS—� v B BOOSTER -®® s ®® I3 1,, CONVERSION[3URIVEP, v — COOK STOVE DIRECT VENT HEATER _milliblan- _ DRYER -- FIREPLACE v FRYOL �_� FURNACE v -- GENERATOR � GRILLE 11111111111111111MESIIIIIIIIIII _al — � �-� - INFRAREL>HEATER _JMAKEUP AIR UNIT v1111 --- OVEN v _ POOL HEATER ______MI riMuLl7T41111.11. --- ROOM;SPACE HEATER v rill Nimi...1111111 ' MINI WIN 11111 111111111Willilnwall TEST TOP UNIT UIVIT HEATER . .-- . ® ®�® S■� r_� UNVENTED ROOM HEATER WATER HEATER II M _— _ _ OTHER I v..I.. haveI a c INSURANCEv�- urrelryt laahih COVERAGE _____IIinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW NO 0 • LIABILITY INSURANCE POLICY [ j'' OTHER TYPE INDEMNITY ❑ BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required ❑ Massechus.etts General Laws,and that my signature on this permit application waive;this requirement. 9 g ed by Chapter 142 of the v q k. .� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER �� I hereby certify that all of the details and information I have submitted or entered regarding this application 0 AGENT ❑ and that all certify plumbingthat work p and installations performed under the permit issued for this application will be in compliance with all P inent provision Massachusetts State wlum bin CodePP cation are true and accurate to the best of my `Z g and Chapter'142 of the General Laws. G knowledge PLUI�4BER GASFIT'fER IVAI��L� G( ''LfrtA , • ' l W P i of the LICE(VSE# MP❑ MGF❑ JP ❑ JGF❑ LPGI S GNATURE ❑ CORPORATION❑JF A r6,P COMP/-‘I Y LAME 0 it PARTNERSHIP❑�� LLC CITY ADDRESS STATE • ✓ FAX TEL _! Tj c✓ } •_ CELL EMAIL'11 )