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Home My WebLink AboutBLDG-23-001502 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK x CITY YARMOUTH MA DATE September 21,202 PERMIT# BLDG-23-001502 i JOBSITE ADDRESS 50 REFLECTION WAY OWNER'S NAME SHERMAN MICHAEL F G OWNER ADDRESS SHERMAN KAREN J 2528 ROYAL PALM WAY WESTON FL 33327 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 1 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 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❑ LPG' ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbridena Qmail.com S310N M3IA321 NYld # $:33d ❑ ❑ lI111,13d 3H1 Ski S3A213S NOIlki011ddki SIHl ON saA S310N N01103dSNI 1YNId AINO 3Sf1210133dSNI NOd 3OVd SIHl S31ON NO1133dSNI SVJ HJfOUJ 11 ':.:Ii-r-1/V-: '.7.1 MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM GAS FITTING WORK fn=n � 6s � CITY :: MA DATE �Z PERMIT t3 - j uZ 1tis � JC)BSITE ADDRESS G.f71/" 1 kkr ti'NE S NQME (�L- t 9n � G OWNER ADDRESS 6ÔT (012_ — ® iax TYPE OR PRIN T OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ Id APPLIANCES c: - JBSM T FLOORS-4 1 ? 3 1 5 6 BOILER 9 11 �? I3 1- BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER, _Z_ _ i FIREPLACE i FRYOLATOR -----_________i FURNACE GENERATOR GRILLE ,_J INFRARED HEATER i . REcE LABORATORY COCKS s _ ED MAKEUP AIR UNIT OVEN ! Q -0 POOL HEATER U�Pg ROOM I SPACE HEATER BLt�i7rrVZ; RTIV1 `Nr ROOF TOP UNIT _ E TEST ___ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I OTHER I [ I I I I INSURANCE COVERAGE I I have a current liabiii insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 I IF YOU CHECKED YES, PLEASE INDICATEYES A' NO ❑ 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 rer{uirer! by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. _._. � +;.apt. SIGNATURE OWNERCHECK ONE ONLY: OWNER ❑ AGENT ❑ I` I OF OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true `� and that all plumbing work and installations performed under the permit issued for this application p t e and accurate to the best of my knowledge �'. Massachusetts State Plumbing Code and Chapter 142 of the Gone will be in compliance with all Pertinent i / provision i al Laws. P n of the PLUMBER-GASFIT-IER, NAME Li j / 76 CL LIC ENSE # SIGNATURE MP ❑ MGF ❑ JP 1:14 JGF ❑ LPGI ❑ CORPORATION ❑ > C1'CP.' PARTNERSHIP 1❑ �r LLC 0 It COMPANY NAME P _ ADDRESS 3 //, ___44CITY A STATE `� ZIP __42h2_aZ_ TEL FAX CELL EMAIL 11 --I v s GCS z42k ROUGH GAS I SFE C'I'IOI'�( NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT it PLAN REVIEW NOTES