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Home My WebLink AboutBLDG-21-005103 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK trl BLDG-21-005103 11=- CITY YARMOUTH MA DATE March 09,2021 PERMIT#JOBSITE ADDRESS 57 BEACH RD OWNER'S NAME BOUND GENE L JR G OWNER ADDRESS 57 BEACH RD WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: D 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 1 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 1 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 0 JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbride(a@gmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .311 M-1 CITY MA DATE PERMIT-# DG I —(36 1U J JOBSITE ADDRESS OWNER'S NAM 444,4elf‘i.7611 GOWNER ADDRESS �EL —alp FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [1 RESIDENTIAL . PRINT CLEARLY NEW: RENOVATION: ig" REPLACEMENT: 11 PLANS SUBMITTED: YES CX.,NO ❑ APPLIANCES Z 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 r — UNIT HEATER UNVENTED ROOM HEATER J WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESrtj NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE 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. CHECK ONE ONLY: OWNER AGENT n 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 Cade and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # SIGNATURE MP ff MGF ❑ JP I►: JGF LPGI ii CORPORATION [ # PrO P PARTNERSHIP # LLC n # COMPANY N i �" ADDRESS ie-4.1 r7G d fi v e CITY N U r STATE ZIP 2/If 7 3 TEL 71Y7/, ? --� M � FAX CELL EMAIL • M r t .lire L-07117ru ntvcuu.rr uj.wLrussu - - ''cam . �� .Dep rrfinetrt oflridustrialAccidents . Ef fill' 1 Congress Streit,State_100 " • - ..? BOSton,M4 0211•'2017 - - - -`,•:-, -._ tpJVW.placcgoy/dur • Y Workers!Compensation Insurance Affidavit Bnrlders/Contractors/I;Iectricians/Plumberg. TO DE ITLF.D lirIIH tart.PERMITTING AU 1H ORTIY. Applicant Information PIease Print Legibly Nainp (Business/Organi2ation/Indhridual): Address: • t City/State/Zip: Phone it: ' Ar=xou au•omploycr?[,Jmcckthe apprnpriatc bo= Type of project(reclnired): LEI I arrr a cmploycr with employees(full and/orpprt-tint)_* 7- ❑New construction - . 2.111.Tarn-a Sol.propridor or partnrsship and bavc no anploycs working for me III g_ 0 Remodeling • • any capacity.[No workers"camp.insurance required.] . 9. ❑Demolition 301 arri a hornarwncr doing all work myself No warkcri camp:inswanccroquird.]t 1 D❑Building addition . 4.❑I am a bommwner nod will be hiring contractors to conduct all wort`cm my papacy.I will cmr,t that all contractors citherhavcwotha-r,"compcnsation insurance or arc solo 1 L[]Elerir-icat repairs or additions proprietors with nocmployaz • • - 12.Q Plumbing repair'soradditions 5.0 leas a general contradorand 1 have him the sub-eontadors licks!on Ilia attached shy 13.n1Zoofrepa- 'Meese sub-connectors have employws and havewotk,-r comp.i surnntzr • lion crMGL c. 14.❑Other • tm 6.0yre arc a rporation and its�rsss have caa asr�theirrightofrxmr P per kl(4),and we have-no employed.PN warfare ramp.insanus=r=gmn$] . ' *Amy 5pplic ntthatchecks bcrxW l must also Ell out thc sctir m bdowsirawingthcu-wackrss'carnpanation policy irrarmatior t gran COWD=S who submit this sf5darit indimtbsg they are doing all work and tbcn hire outside caribactors must submit a new affidavit iadimting such. I-Contract ors that check this box must attached an additional shcctahowing the mesa nfthe sob-animators and state whdha or not those entities Nava cmployecs. Lf the sub-cmdadars have O mpJoyrss.they must provide their workase camp,policy mmmber. ear =engirt lyre abatis'previ.dtngit'nrkerr'conTenstrtion inraranr-for my caTloycrs_ Belalr.ir-the policy wrdjob site _ i rfor77rtrtlorr. - - Insurance Company Name: • . . Policy#or Self-ins.Lie-_#: ExpirationDatt:: • Job Site Address: • - City/State/Zip: Attach a copy of the workers'compensation policy declaration page(sbowing the policy number and expiration date). Failure to secure coverage as requiredunderMGL c.152,§25Ais a criminal violation punishable by afne up to$1,50D-00 and/or one-year imprisoruncnt,a- well as civil penalties in the form of a STOP WORK ORDER.and a fine of up to V 5O.DD a _ day against the violator.A cony of chit statancat may be forwarded to the Office oflnvestigations of the DIA for insurance coverage verification_ . I do hcrchy certify undfftfrepauu m rip nxaltirr ofprrjrrry thdike infarmaiion prorided above is frue and correct. Signature: Date: • Phone i . Offirfrr7 use only- .Do n.ot 3trtte irr this=cc,to be camp f{rrl by city ortmrrr ofjlrirrT city or Town: Pcr olit/Lictnse# Issuing Authority(circle one): • • 1.Board of Health 2_Butlding-Deportment 3-CityITown Clerk 4.Electrical lnspnear S.Plumbing Inspector • E Other Contact Person: Phone#_