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Home My WebLink AboutBLDG-21-006968 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k4e,, �I__ CITY YARMOUTH MA DATE (June 02,2021 'PERMIT# BLDG 21-006968 JOBSITE ADDRESS 812 ROUTE 28 OWNER'S NAME NIKOLAIDIS ROSEANNA TR G OWNER ADDRESS ROSEANNA NIKOLAIDIS RLTY TR 4 VINEYARD CIR SAGAMORE BEACH MA TEL 02562-2740 TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT IDRESIDENTIAL ID CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 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 0 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 MP 0 MGF 0 JP ElJGF 0 LPGI 0 CORPORATION 0#) I SIGNATURE I PARTNERSHIP ❑#I ILLC 0#1 I COMPANY NAME: 'MICHAEL R MCBRIDE I ADDRESS. '9 Rustic Drive, CITY (West Yarmouth I STATE IMA I ZIP 102673 J TEL FAX I I CELL I 'EMAIL stinger.mcbride@gmail.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO P -FORM GAS FITTING WORK - CITY: i. - C /14, O u �� MA. DATE: Alt PERMIT#L�i !�L zl-dn6n '9 BSITE ADDRESS: ' ) /, / G OWNER'S NAME >�i OWNER ADDRESS:_( � r TEL? TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL 114 NEW;❑ RENOVATION:❑ REPLACEMENT:❑ APPLIANCES? FLOOR—, Bsmt PLANS SUBMI I t tD: YES El NO 6-4BOILER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE lr} INFRARED HEATER 141 LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER J ROOF TOP UNIT $ TEST UNIT HEATER +tj UNVENTED ROOM HEATER WATER HEATER INSU CE CORAG I have a current liabili insurance policy or its substantial equivalent which meets t}a requirements of MGL Ch.142 YES 0 NO ❑If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Cif. OTHER TYPE INDEMNITY ❑ BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 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 0 hereby certify that all of the details and information I have submitted(or entered) Knowledge and that all plumbing work and installations performed under the permit issued for this application win be Ining tis alication are trued amptanceto the best of my with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME; (( (J (fie , p,f/�. LICENSE# f'i U/�p� SIGNATURE COMPANY NAME. I, i RESS: CITY: n' STATE:i ZIP:�3 FAX: TEL: CELL_ ��- �jJZ EMAIL MASTER 0 JOURNEYMAN 53- LP INSTALLER❑ CORPORATION 0# E PARTNERSHIP❑# LLC❑#