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HomeMy WebLinkAboutBLDG-21-007317 f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 16,2021 PERMIT# BLDG-21-007317 , JOBSITE ADDRESS 158 BREEZY POINT RD OWNER'S NAME SMITH DOUGLAS P TRS G OWNER ADDRESS HARRIS SUSAN W TRS 7 BRIDLE RD CHELMSFORD MA 01824 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 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 1 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 0 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# 19681 SIGNATURE MP 0 MGF ❑ JP© JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL I FAX CELL EMAIL Istinger.mcbride@gmail.com • -- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES MASSACHUS TTS UNIFORM AP LIGATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'p-�"1Tc vow CITY MA DATE PERMIT# JOBSITE ADDRESS /.S /-i 1V d//,?7 OWNER'S NAME ` /U 19 / f f v7 s GO NER DRES° 77 �% ) 7( ,1i q, ELW r.) FAX TYPE OR (—kV 'T 4M<1IAL OCCNCIFE ❑ E-DUCATIONALk RESIDENTIAL' �1F.Pi ' 134- :-' -4 VNTIC T-2-'- t` f 1t1 .< ..,�_ _- _`r" 7'� B1 `t.`I�O - APPLIAN ES 1 FLOORS-4 BSIJA 1 2 3 1 5 6 7 8 9 10 11 12 13 1 14 I--BOILER ..,, =''BOO TER 1,:..'. CONVRSION BURNER -COOK SI1OVE / DIRECT'\'ENT HEATER L 'bRYER I i `FIREPIA(M- t • I TZYOLFr OR FURNACE GENERATOR. GRILLE INFRARED HEATER I LABORATORY COCKS MAKEUP AIR UNIT OVEN J� POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST . . .� UNIT HEATER INVENTED ROOM HEATER WATER HEATER i OTHER - I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESX NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY Z 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. I. CHECK ONE ONLY: OWNER ❑ 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. (.J, PLUMBER-GASFITTER NAME V i ' ( ,1 c p_` ‘ I I LICENSE# / SIGNATURE MP ❑ MGF❑ JP( JGF❑ LPG! ❑ CORPORATION❑It PARTNERSHIP❑#` LLC❑# COMPANY I AKIE Jv` ( , ) r `kLe, ' Lr '�/l.'� ADDRESS p,� ✓�i '—'''. ' , I v CITYUJ ci, . NI L' L'a I STATE ZIP G�CX/ TEL ` ez)7u FAX CELL EMAIL) `7 0 J�l-, .M C_)j r I "' at 5 RA. I L' (C 00 •r i 1 I i I ClI I �t Cd] I I r 44 1 I .0 z 4 • : W =- G • I_ Cf..! giai W LU G I 6A = I .. co En 0 I Z '‹ c' - ?• _ ... . .. .. .. _ _ En O > 1,1.4 • co C.9 Q Gl C_7 M.1 -a • R. co tii 1 IU- I 1 1 0 1 el C.) I 1 En I 1 I In I C.,I ram. 1 ° 1