Loading...
HomeMy WebLinkAboutBLDG-21-004244 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ., - CITY YARMOUTH MA DATE January 29,2021 PERMIT# BLDG-21-004244 i_�� JOBSITE ADDRESS 28 CAPT DANIEL RD OWNER'S NAME GIBBS DONALD W G OWNER ADDRESS GIBBS CAROLE L 1 RIDGE DR DUDLEY MA 01571 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 12 PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO ❑ FIXTURES FLOORS—• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 1 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❑ 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❑# 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 PER IT TO PERFORM GAS FITTING WORK -2s i�y CITY , rc i _ MA DATE f DZ.. PERMIT#B� - ;/6b y'/ JOBSITE ADDRESS �' 1 T 1OWNE NA � ....a.,. iG �� 1 GOWNER ADDRESS ' r y , / FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION:D REPLACEMENT:14rgi PLANS SUBMITTED: YES D NO cif APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 BOILER BOOSTER M �I CONVERSION BURNER _1111111 1111111101111111 COOK STOVE DIRECT VENT HEATER ME all ,,MI MU ME OM MI MN Mir Om MI _,,,.,,,, NM ..... ,,,, DRYER FIREPLACE 111111,1111111 INS IIIIINIIIII IIIIIIIIIIIIIIIIIIII IIIILIIIIIFRR O N NM FRYOLATOR FURNACE GENERATOR3111111111MIIMINIIIIIIIIII(1111111111111111111111111 011111s GRILLE I rIMIMIMMEIr ...tt. INFRARED HEATER Mg __-- AIM IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINIIIIIIIIIIIIIIIIIIIIIIM LABORATORY COCKS MAKEUP AIR UNIT liairaiii3M401.10.11 OVEN r : 1 k a. - a POOL HEATER -illiniiiiiiiiiralitgillis ,,.. .Oligiallillilliiiiilari MIK O.gni:,1111 ROOM/SPACE HEATER a14 lilt ROOF TOP UNIT �r �.._ro._.. .. I __....�. ilialIMIIIIIIIIIIIii TESTIIIIMMill'orarinaram MN UNIT HEATER ..,,,, . inniammions gut UNVENTED ROOM HEATER I r ,{,- i L I WATER HEATER � ... OTHER NMI MI MO NI MI ,01111 �W I#� miimm.F...:: INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 11 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 24 OTHER TYPE INDEMNITY rip BOND LI 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 Li 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 c pliance wit all Perti nt provisioue the Massachusetts State Plumbing Code and C apter 142 of the General Laws. /� ,\ (� (�`mil�...)__ PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP El MGF Li JP JGF LPGI CORPORATION Litt API, PARTNERSHIP # J LLC # V COMPANY NA : C8 f i Ixt' ADDRESS, 9 r W`., CITY jjJ �G ' vi L . __ _li STATE i ZIP.. At.. �#�!-�'TEL n lard.. FAX CELL EMAIL. • f` Vq-it....