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Home My WebLink AboutBLDG-21-007409 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 CITY YARMOUTH MA DATE June 21,2021 PERMIT# BLDG-21-007409 ``5 OWNER'S JOBSITE ADDRESS 57 WINTER ST 0 S NAME BELESS CLAYTON W G OWNER ADDRESS BELESS NANCY L 57 WINTER ST YARMOUTH PORT MA 02675-1247 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: D 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 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 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 0 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 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.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 ~r } MASS HUS TT UNIFORM i�l� APPLICATIONFEE A PERM/FT FT TOPERFORM GASFITTING WORK CITY MA6 / '77e,-/ l�PERMITQ -Z( -C�G'7'i o JOBSITE ADDRESS .$ 7 14 /4 „--` 37 - OWNER'S NAM G OWNER ADDRESS 77 TEL7 7<3 7 7 0 _ FAX TYPE OROCCUPANCY TYPE COMMERCIAL EDUCATIONAL "_ �- ,�T [� DU�A'i ICif�AL 1,= R`SIUENTIAL, NEW`: _- REfiNOVATtON: ❑ • { EPLAC t4 'r`- :.- _.r ; PLANS sUBl IT as --.'/In ❑c NO IX APPLIANCES 4 FLOORS-- BSlul 1 ? 3 4 5 6 7 8 9 10 11 12 '13 14 BOILER i BOOSTER CONVERSION BURNER COOK STOVE I DIRECT VENT HEATER DRYER FIREPLACE FRYGLATOR i FURNACE GENERATOR -I GRILLE INFRARED HEATER LABORATORY COCKS I MAKEUP AIR UNIT I OVEN i� POOL HEATER ROOM / SPACE HEATER ROC)F TOP UNIT TEST Ci -. - - - _.... UNIT HEATER LJNVENTED ROOM HEATER I I WATER HEATER i OTHER i I 1 INSURANCE l SURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES , NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY K OTHER TYPE INDEtii BOND fl INITY ❑ I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required byChapter ter 142 of the l Massachusetts General Laws, and that my signature on this permit application naives this requirement. CHECK ONE ONLY: OWNER `1 AGENT 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. �l i J 1 -r LUMBER GASFIT TER NAME LICENSE # Q.)\.__.. c •----A.,.............._ P SIGNATURE MP E MGF n JP _ JGF C LPGI n CORPORATION ❑ >: PARTNERSHIP ❑ # LLC COMPANY I\AM Nt ,:jr- ic:Q., £1s - ' ADDRESS9 4 r CITY _ q C NI C 0 STATEshi_ ZIP0 .1,(4)73_ TEL / za i FAX CELL EMAIL k7 i'l, -el' . (1-1 C_J) r.a c,94;) V t 1 • G1gra 0. 1 1 1 1 I r I i i I i 1 i I I Z G «O . w -- I c1 I cwa [a °_LII G 4 I 04 z w .. _ . o U Z. -a Q ' II I e il = ill r u.. I 1 1 i I C) G 1 I w 1 4 I I O 1