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HomeMy WebLinkAboutBLDG-23-001416 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTHk,,,, r —1 MA DATE September 16,202 PERMIT# BLDG-23-001416 JOBSITE ADDRESS 1151 BAYVIEW ST`30 A- Ap-1;•45-6,,,)OWNERS NAME KACZOWKA WILLIAM J G OWNER ADDRESS KACZOWKA NOREEN A 39 CHESTNUT ST SEEKONK MA 02771 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El 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 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 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 0 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 0 JP© JGF 0 LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: MICHAEL R MCBRIDE ADDRESS. 9 Rustic Drive, CITY West Yarmouth STATE MA ZIP 02673 TEL FAX CELL EMAIL stinger.mcbride a(�.gmail.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 5-0. DO • .g rj. A V E OP SACHUSETTS UNIFORM APPLICATION FOR A P MIT 0 PERFORM GAS FITTING WORK a. r CITY ye,/' MA DATE ZQ PERMIT*.52322 JOBSTE ADDRESS OWNER'S NAMEgiat_ki_r_zZadieitt B ILDI LPAR5 IDDRESS A : SO TEL TEL FAX FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:X Mew` PLANS SUBMITTED: YES❑ NOVI APPLIANCES 71. FLOORS BSM 1 2 3 1 5 6 7 8 9 10 '11 12 '13 1R BOILER BOOSTER CONVERSION BURNER COOK STOVE • DIRECT VENT HEATER _J— ' DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR I ,GRILLE INFRARED HEATER LABORATORY COCKS J MAKEUP AIR UNIT OVEN POOL HEATER • 1 ROOM I SPACE HEATER ' •ROOFTOPUNIT TEST UNIT HEATER • UNVENTED ROOM HEATER �~ WATER HEATER OTHER . 1 _ II INSURANCE COVERAGE i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee sloes 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 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 i compliance with all Pertinent provision of the •= Massachusetts State Plumbing Code an Chapter 142^`of the General ws. ' PLUMBER-GASFITTER NAM= t C e L `_ � (-1 LICENSE# SIGNATURE "1.--"' MP ❑ MGF❑ (�`JP ❑ JGF❑ PGI❑ CORPORATION❑it A ro e •PARTNERSHIP❑if LLC❑# COMPANY \LAME 1 V`( C / 0 f ADDRESS 37 frqii l / 6/r 4(A CITY a nil l 5 STATEAlf_ ZIP or ?.(p e/ TEL 77V SM 7/iz FAX CELL EMAIL i �8 /����� �e-j/../��, 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 • •