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HomeMy WebLinkAboutBLDG-23-001415 • _-,— r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • ,: f< CITY YARMOUTHiktrt J MA DATE September 16,202 PERMIT# BLDG 23-001415 ll JOBSITE ADDRESS 1151 BAYVIEW ST(301 4.1..,5-r..,) OWNER'S NAME KACZOWKA WILLIAM J G OWNER ADDRESS KACZOWKA NOREEN A 39 CHESTNUT ST SEEKONK MA 02771 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ID PRINT CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 1 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 El 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❑ 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(D.pmail.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 UNIFORMAPPLICATION FOR A PER' 'IT TOPERFORM GAS FITTING WORK :e,; I t4t V. I n ."I'--` .CITE` .. `,/ !/ i I� MA DATE I Z2 PERMIT# -- 17/,� trtP 15 IT: AN RES I I. �, /,-.. Iiv 1.....) OWNERS NAME 8i L� (20t )Z‘, BUIt'H. DE_•A rW �NTDIR,ESS 0TTEL gf!!I`,_/7-(� FAX I ayry-�,� . L, "- Y TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL X. INT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO rd APPLIANCES 1 FLOORS-4 Boul 1 2 3 th 9 10 11 12 13 BOILER © BOOSTER CONVERSION BURNER COOK STOVE re, -n IP - i / _ DIRECT VENT HEATER 1 1 DRYER �--- I FIREPLACE _ FRYOLATOR ___1 GENERATOR GRILLE I INFRARED HEATER i LABORATORY COCKS I H k4AKEUP AIR UNIT OVEN I______' POOL HEATER ROOM I SPACE HEATER ' ROOF TOP UNIT _/. . UNIT HEATER LINVENTED ROOM HEATER I WATER HEATER . —= OTHER I 1 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU.Ch.142 YES, ] NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ge 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 '3:!, 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 an Chapter 142 of the General aws. /7j/T/ n t, ,. _ PLUMBER-GASFITTER NAME ' 6te t/ " 3 P i LICENSE# SIGNATURE MP ❑ MGF❑ JP iyl JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP I LLC❑# COMPANY NAME 1 V 1 r r f P k ADDRESS .3/ P1 /1(6L/✓1 4/4"v kzLL////%e CITY H-7 14 A L f STATE ZIP 6 (4,6 / TEL Z7Y 41 d 7�7/� FAX CELL EMAIL . t l /L . coAI 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