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HomeMy WebLinkAboutBLDG-23-003132 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �, 7, CITY YARMOUTH MA DATE December 07,202; PERMIT# BLDG-23-003132 II _: JOBSITE ADDRESS 5 DUNDEE DR OWNERS NAME Laurie Quinn G OWNER ADDRESS 5 DUNDEE LN YARMOUTH PORT MA 02675-1518 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: 0 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 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 0 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 ❑# LLC ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbrideagmail.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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t 0 A 6' CITY 1 /�� MP, DATE 3 /7.z PERMIT# Z� JOBSITE ADDRESS OWNERS NAME L12C 1-L urz. &u1 A OWNER ADDRESS M D TEL7Z2• jFA.X TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL , PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: (c PLANS SUBMITTED: YES R.NO❑ APPLIANCES FLOORS— BSlul 1 2 3 4 5 6 7 8 9 10 11 12 13 1! BOILER BOOSTER _ CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE • FRYOLATOR FURNACE GENERATOR GRILLE C INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER -R E4I \E D ROOM I SPACE HEATER ? ROOF TOP UNIT C 2 TEST . ... . ..-.... aC J 05 202 UNIT HEATER .311 D tvC TM EN j UNVENTED ROOM HEATER 6 WATER HEATER --j OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES f NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Di 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 ❑ SIGNATURE OF OWNER OR AGENT 711-• 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 `Jt Massachusetts State Plumbing Code and Chapter 142 of the General Laws. F /yy PLUMBER-GASFITTER NAME MI CAL ( 3 f te2.11 LICENSE# SIGNATURE MP ❑ MGF❑ JP ❑ JGF❑ LPGI ❑I �/)CORPORATION❑# PARTNERSHIP❑#/ LLC❑# COMPANY NAME R C. r t i l?- ADDRESS -a 7 �/4 /(l /!fi4e4 V CITY / 4 411. $- STATE ' •ZIP fl 2-(d r TEL 77 / Ydio 1/L z. 1111 FAX )V CELL ��— p/z-J EMAIL 5 r7y2/--, C rrCQo 1t^ iL. on,, ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTEi c • Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES