HomeMy WebLinkAboutBLDG-22-002888 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
w' CITY YARMOUTH MA DATE November 18,202'PERMIT# BLDG-22-002888
JOBSITE ADDRESS 48 SEAVIEW AVE OWNERS NAME Tom Ives
G OWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ 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 1
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
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 0
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❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive,
CITY West Yarmouth I STATE MA ZIP 02673 TEL
FAX CELL EMAIL Istinger.mcbride(a.gmail.com
S310N M31/13b Ndld
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
001-11 \
:-11:0CITY K/
A DATE/lie) Z_D i/ PERMIT# 77- Z ''
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JOBSITE ADDRESS ,4 U/t�.n.1 j/q-ij ' OWNER'S NAME 7/(p' S
GOWNER ADDRESS TEL FA?;
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL KI
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: g �5 PLANS SUBMITTED: YES® NO E
APPLIANCES 1 FLOORS-t BEM 1 2 3 4 5 6 7 8 9 10 11 12 1 14
BOILER ---i
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER 3 I —7
DRYER
FIREPLACE —�
FRYOLATOR
FURNACE
GENERATOR I
GRILLE -
INFRARED HEATED.
LABORATORY COCKS —�
MAKEUP AIR UNIT
OVEN - '
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT T
TEST . . ._. . ... . . . . ._ .._ ..-.._ . . V • - ---
UNIT HEATER
INVENTED ROOM HEATER —
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I'NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ce 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 ❑ AGENT El
SIGNATURE OF OWNER OR AGENT
G., 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
`k- 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.
Lo
PLUMBER-GASFITTER NAMr ((rCJ/1 bicityr 1 LICENSE# Os
ATUR
MP❑ MGF❑ JP ag. JGF ElLPGI El CORPORATION❑# W 4 PARTNERSHIP El# LLC El#
IV '
COMPANY AME 3r l P+ it ADDRESS 3 7 ,Cris L-�/) At C .
CITY G!) 413 STATE_A44. ZIP 0 Z.6 Q / TEL 77 Y /G , Z?
FAX CELL EMAIL 54--i P C Qi--- ., c C ,4 ) n ,-•�t c//LC'1
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