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HomeMy WebLinkAboutBLDG-23-003134 - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7 CITY YARMOUTH BLDG-23-003134 1 M I MA DATE December 07,202, PERMIT# i__ ' JOBSITE ADDRESS 1777 WEST YARMOUTH RD OWNER'S NAME IDEARDEN LAURIE A G OWNER ADDRESS 777 WEST YARMOUTH RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL El 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 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 El 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 SIGNATURE MP 0 MGF 0 JP© JGF❑ LPG( ❑ CORPORATION 0#I I PARTNERSHIP ❑#I ILLC 0#) COMPANY NAME: 'MICHAEL R MCBRIDE I ADDRESS. 19 Rustic Drive, CITY 'West Yarmouth I STATE IMA I ZIP 102673 I TEL I I FAX 1 I CELL I I EMAIL Istinger.mcbride(cilpmail.com I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,." g61T* CIT49 `( i r. Q tf f f tx G � - MA DATE - 3 13 iffr -� PERMIT�; �1 JOBSITE ADDRESS s OWNER ADDRESS t G I I OWNER'S NAM TYPE OR1 ��� FAX OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY tJEW:❑ RENOVATION: ❑ REPLACEMENT` PLANS SUBMITTED: YES❑ NO APPLIANCES t FLOORS-4 8CM t Eimuninimmo BOILER 5 F .......1, BOOSTER _5„, - � 13 1,, CONVERSION BURNER DIRECT VENT HEATER - DRYER -- - FIREPLACE C i FRYOLATOR ---I-- ®— FURNACE GENERATOR = = GRILLE - _ �— INFRARED HEATER ______I LABORATORY COCKS MAKEUP AIR UNIT . war,1+111, 11____________!r� OVEN „ POOL HEATER �� �- ROOM!SPACE HEATER �M�Z ROOF TOP UNIT M NT - TEST IIIHNI DINt�RT— ~ UNIT HEATER —�� M UNVENTED ROOM HEATER __ WATER HEATEROTHEt; imillian 111111.1111...............01111111 al ..... ••0..E will ni..., I have a current IiaBili insurance policy or its substantial equivalent INSURANCE E COhVER iG the I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX B O 'Ch. 42 YES NO E] W LIABILITY INSURANCE POLICY atf OTHER TYPE INDEMNITY D BOND • OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage ❑ Massachusetts General Laws,and that my signature on this permit application waives this requirement°1Breci by Chapter 142 of the C. v ''N SIGNATURE OF OWNER OR AGENT CHECKONE ONLY: OWNER rn-� '�I• I hereby certify that all of the details and information I have submitted or entered regarding this application �! AGENT 0 > ande that alle certify plumbingthat work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision Massachusetts State Plumbing Code and Chapter 142 of theP pp n are Prue and accurate to the of my ; L? Ge ral Laws. best knowledge PLUMBER-GASFITfER NAME pp,, p sion of the MP ❑ MGF❑ JP LICENSECACItia # SIGNATURE C JGF❑ LPGI ❑ CORPORATION❑/E COMPANY NAME r PARTNERSHIP❑# LLC CITY ADDRESS i STATE FAX ZIP TEL CELL EMAIL Ar y _ • IA I