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HomeMy WebLinkAboutBld2-22-000507 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE July 27,2021 PERMIT# BLDG-22-000507 JOBSITE ADDRESS 154 WOOD RD OWNER'S NAME CATSOULIS GREGG A G OWNER ADDRESS CATSOULIS ELIZABETH P 0 BOX 1029 SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ 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 ❑ OTHER OF INDEMNITY El 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 Jason Chigas LICENSE# 26665 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: JASON L CHIGAS ADDRESS. 106 RIVERVIEW AVENUE, CITY WALTHAM STATE MA ZIP 024535014 TEL `l -a3J 3 FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE'S Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ O 2/2 7 FEE: $ PERMIT# PLAN REVIEW NOTES A:::,.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �,.a I. � , K_= — ti _`� CITY _ _ ,o� � �, MA DATE °-L- 2.4--IA,.,1 PERMIT# -(, 7 JOBSITE ADDRESS \ �- Lim�.,c,� �� I OWNER'S NAME c•.�o,\ C,u,\ ,,c,.. GOWNER ADDRESS TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL IQ- PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO ID APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER 1 DRYER FIREPLACE FRYOLATOR vo,_; Iry . FURNACE NIE MGENERATOR • IIIM I/11 IR , GRILLE INFRARED HEATER 11111M11 LABORATORY COC al I 11/4111111111111111 MAKEUP AIR UNITga OVEN BUILDING DEP'RTM ill POOL HEATER .111.t ROOM/SPACE HEATER ROOF TOP UNIT 1 1 I TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER te OTHER I INSURANCE COVERAGE I have a current liability insurancepolicyor its substantialequivalent which meets the requirements req manta 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 0 OTHER TYPE INDEMNITY Ej BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee dose 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 0 AGENT El SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application re 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' compliance 'th all Pe 'nnn 'sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. lam'Z-‘k PLUMBER-GASFITTER NAME L, LICENSE# 2to66 SIGNATU MP MGF EI JP® JGF Ej LPG'0 CORPORATION # PARTNERSHIP DO j LLC #L COMPANY NAME: ADDRESS I '` , t � v I CITY LU A ,p,, STATE UMtq ZIP L,5,2Z%.4-53 ITEL -94181 qCa<< 23 C3 FAX CELL EMAIL. - --o` w`