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Home My WebLink AboutBLDG-21-006063 _r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1111 i• CITY YARMOUTH MA DATE April 21,2021 PERMIT# BLDG-21-006063 k.,,,, JOBSITE ADDRESS 3 BUTTERCUP LN OWNER'S NAME KURTOWICZ PETER L G OWNER ADDRESS KURTOWICZ MAUREEN T 3 BUTTERCUP LN SOUTH YARMOUTH MA 02664-1105 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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❑ 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 0 JP❑ JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY `West Yarmouth I STATE MA ZIP 102673 1 TEL FAX 1 1 CELL 1 1 EMAIL stinger.mcbridel 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 1CN, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1= CITY: O '` ..1 rl11 r)LI MA. DATE: 171/e1 A-4 PERMIT# JOBSITE ADDRESS: !'f I)7- 'J'r.U P 1.-_cj fse OWNERS NAME: (1ref b.) r 7 ( I i C_7_ GOWNER ADDRESS: 5-DY TEL:- / 2i- y y I FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY I NEW:t RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO(,g APPLIANCES? FLOOR-• Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER / , BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I DRYER _ I. FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE +A INFRARED HEATER , ;? LABORATORY COCK . . MAKEUP AIR UNIT rJ OVEN . fi POOL HEATER ROOM/SPACE HEATER _ �) ROOF TOP UNIT fi TEST ' UNIT HEATER +L UNVENTED ROOM HEATER WATER HEATER _ 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES it NO ❑ tf you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY a 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 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT 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. /,, J \ ` �( PLUMBER/GASFITTE NAME: \ P j� � 4— LICENSE#/?�/7/ �J�r ilIGNATURE COMPANY NAME: `� ( t' I F '1 (!l'l a l ADDRESS: ( B I /L/ e CITY: A) r 4 rivi6)V,` STATE: ZIP: 07&`3 FAX TEL:7 7 y qt 1 O 67IV CELL: EMAIL: .1-1 n • r-i 0 4-•/L, - MASTER 0 JOURNEYMAN 29--LP INSTALLER 0 CORPORATION❑#P r0-P PARTNERSHIP❑# LLC 0 c h'i 41 L ADD2e--.ss : ._ _