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HomeMy WebLinkAboutBLDG-23-000742 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ........._....__-__ R a CITY YARMOUTH MA DATE August 12,2022 PERMIT# BLDG-23-000742 JOBSITE ADDRESS 77 PINE GROVE RD OWNER'S NAME RODRIGUES MARIO G TRS G OWNER ADDRESS RODRIGUES MARIA J 78 GARDEN PKWY NORWOOD MA 02062-1752 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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 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❑ 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 LICENSE# 19681 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbride(a5,gmail.com S310N M31A321 NVld #1IW213d $:33d ❑ ❑ 1IWN3d 3H1 SY S3A2i3S NOliv011ddtl SIHI oN saA S310N NOI103dSNI lYNId AINO 3Sl 210103dSNI 2IOd 39Vd SIHl S310N NOI103dSNI SVO HOfON '_�iP MASSACHUSETTS UNIFORM APPLICATION FOR A P M T R TO PERFORM GAS FITTING WORK y GNP CITY 4 cy . (� 0 I ` DATE . Z c PERMIT �;. Ft EC: E 1. . ..,E `DDRESS � � _ 7 7 ( t 6lC:C'J - OWNER'S NAME M44 j P 4 W- /IJ R AbDRESS 2 T" 4 r( I J c,r-(,,( 7 Ff 12 BOLL TEL � -� �'y FAX --- I OCCU AP CY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL, U IIF� p• RTMENT IUEI�fTIALJ -y: -- 1,IF'►N* 0 RENOVATION: ] REPLACEMENT: ❑ PLANS c YES r'LAI��I`, SUBMITTED: l `S ❑ N0 ❑ APPLIANCES FLOORS—+ Bclyl 1 2 3 1 5 6 7 o BOILER 9 10 1.1 12 I3 1,, BOOSTER CONVERSION BURNER --� COOK STOVE r,12 pow (o i _______L____ DIRECT VENT HEATER DRYER ; l FIREPLACE FRYCiLATOR i FURNACE — GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS ----1 MAKEUP AIR UNIT OVEN --__________L_J ---1 POOL HEATER -#___ ROOM ! SPACE HEATER ROOF TOP UNIT ------, TEST I . . . . ._ UNIT HEATER UNVENTE D ROOM HEATER _ J'� WATER HEATER OTHER INSURANCE I lave a current 16a bili insnc�ance policy ar its substantial equivalent COVERAGE which meets the requirements of lIf1GL. Ch. 142 YES Z NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ,` OTHER TYPE INDEMNITY ❑ BO• ND ❑ 1 OWNER'S INSURANCE WAIVER: l am aware that the licensee does not have the insurance coverage required 4 Massachusetts General Lars, and that mysignature on this permit application waives this. . trecl by Chapter 142 of the ' '� permit Pp _._ 7�s requirement. ' SIGNATURE OF OWNER OR, AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ "�:: I hereby certify that all of the details and information 1 have submitted or entered regarding 's _ and that all plumbinge work and installations performed under the permit issued for this application application are true and accurate r the best knowledge Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p be in compliance with all Pertinent provision of the `I PLUMBER-GASP 1 IT TER NAME .s.-/ LICENSE # .k SIGNATURE MP ❑ MGF ❑ JP tk JGF ❑ LPGI El CORPORATION ❑ t PARTNERSHIP 1 .RTNER.SHI P Elr LLC ❑ COMPANY NAME ` . f t ADDRESS CITY _ i - STATE li1/44- ZIP O L 6 / TEL7 T FAX, � C, CELL EMAIL is • .Ai '! ; . . .. ROUGI GAS INSPEd'TION I'fP TE,S THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES • • • •