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HomeMy WebLinkAboutBLDG-23-00010 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE July 01,2022 PERMIT# BLDG-23-000010 JOBSITE ADDRESS [7 FRESH BROOK RD J OWNER'S NAME Brian Davis G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL 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 DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:move gas meter 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 0 OTHER OF INDEMNITY CI 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 It 19681 SIGNATURE MP❑MGF 0 JP© JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbndeaomail.com S310N MIA NYld #.I1/0:13d $:33d ❑ ❑ 111183d 3141 SY S3Ab3S N011V011ddb SIHJ oN so), S310N NOI103dSNI 1VNId AlN0 3Sf1 230103dSNI 2IOd R Vd SIH1 S310N N01103dSNI SVD HOflO v �f�4l4£.SACH SETTS UNIFORM APPLICATION FOR A PE MIT TO PERFORM GAS FITTING WORK 17N1 -- C GrrrtDu:: MA DATE Z 2 PERMIT# Z 3 •- Du!O JU N 30 ?Aim- A(SDRE•55�1 S� co Of� } OWNER'S NAME / J T/ r! I �/ 5 BUlL , ' DEF-A t' E �,D�RESS 3 TEL — 6��S FAY, PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL V CLEARLY NEW:❑ RENOVATION: Q REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS BSlul t ? 3 5 s 7 9 to 11 12 i BOILER 1= ' BOOSTER I { CONVERSION BURNER --1 --_, COOK STOVE DIRECT VENT HEATER I DRYER �' FIREPLACE i FP,YOLATOR I FURNACE _I GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS i •MAKEUP AIR UNIT _� OVEN _� POOL HEATER • ROOM!SPACE HEATER ROOF TOP UNIT TEST —~ t UNIT HEATER . .. _.._ I UNVENTED ROOM HEATER WATER HEATER y OTHER /Ln y� vp, k v i / f I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES\] N0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ • I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the fMassachusetts General Laws,and that my signature on this permit application waives this requirement. . �► CHECK ONE ONLY: OWNER E AGENT El .� 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. t 11Q (aT/ PLUMBER-GASFITTER NAME V -1 *i ukkote 1= r‘CYQr LICENSE# SIGNATURE MP ❑ MGF❑ JP VL JGF❑ LPGI ❑ CORPORATION❑it PARTNERSHIP❑it � A l P+—t+— / / �r❑COMPANYNAME d � r I� ADDRESS �� �-���j �l!� LJJ� ' �., CITY G 7 lJ 4,( S STATE r "NA.— ZIP D Z Co !Q / TEL '7""`� FAX j 77 `���d ���� CELL EMAIL • R V ROUGH GAS INSPECTION NOTE,_ THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 'des N THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT ft PLAN REVIEW NOTES ry