Loading...
HomeMy WebLinkAboutBLDP&G-21-000188 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (July 14,2020 'PERMIT# BLDP-21-000188 JOBSITE ADDRESS 11 PINE GROVE VILLAGE OWNER'S NAME HOLMES JOHN J G OWNER ADDRESS 12945 VANDERBILT DR APT 307 NAPLES FL 34110 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW'. 0 RENOVATION:❑ REPLACEMENT:O PLANS SUBMITTED:YES 0 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 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 1 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 0 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 LICENSEE 119681 SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANY NAME: IMICHAEL R MCBRIDE ' 'ADDRESS. 19 Rustic Drive, CITY 'West Yarmouth 'STATE MA ZIP 02673 TEL ' FAX CELL 1 IEMAIL Istinger.mcbride@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 R T TO PERFORM GAS FITTING WORK ,os - ) CITY d • MA DATE Z 2.0 PERMIT `o7/`dam 1F JOBSITE ADDRESS /V ' r Ili • OWNER'S NAME rO L- 0 A GOWNER ADDRESS e/ 49 TEL FAX TYPE OR L/���� �T OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:V PLANS SUBMITTED: YES❑ NO[a, APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 o BOILER 9 10 11 12 13 14 BOOSTER CONVERSION BURNER, COOK STOVE ' DIRECT VENT HEATER DRYER, __ FIREPLACE I FRYOLATOR - FURNACE GENERATOR GRILLE INFRARED HEATER _ i LABORATORY COCKS __________I MAKEUP AIR UNIT - _--I OVEN 1* POOL HEATER k ROOM;SPACE HEATER ROOF TOP UNIT r TEST �' �7 UNIT HEATER r • �' UNVENTED ROOM HEATER I r ` WATER HEATER ��` '-�-_ 1�� --„I OTHER HER 1/ 1ii INSURANCE COVERAGE ( l I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES cc6 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g. 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 ` Masse husetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR,AGENT "ice 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 an Chapter i42 of the Generat ws. I�yJ1 �Q� / ' PLUMB ER-GASFITTER NAME(NI (;, aeL. M,C)� 1` 1 0* , LICENSE , /^J �� ' CENSE#� /*/ SIGNATURE MP E MGF❑ JP JGF❑ LPGI CORPORATION❑4PARTNERSHIP❑4L Pia P• LLC❑t# COMPANY NA C J ADDRESS Ci 0 0 5/6 OricA7 CITY V .d wr M O L J STATE ZIP V 427'3 TEL ) q ( 7Y � ?/ a a_ FAX CELL EMAIL M pi6la°,5_w4 <e , Li `v 1 1 I rGr,i1 5, Ho I C) I �d I P p^( I Dr1 I I I I 1 l 1 L 0. 2 Ql 1 1 ;41 1 Z H ' 0 LU 0 L) L/ 6T. E- n. W l CO co- . _ I hA., LU LU S, . c Q GJ'. C E''i a. < U14 Ilil -- U.... 4 i. CA 0 C.C.)El CO 1 iI 4 "< I C:4 . ,\ 0 I