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HomeMy WebLinkAboutBLDP-23-005472 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 47 r = r CITY 'YARMOUTH MA DATE April 03,2023 PERMIT# BLDP-23-005472 JOBSITE ADDRESS 130 JOHN HALLS CARTPATH VILL OWNER'S NAME IHIGGINS ELLEN T TR G OWNER ADDRESS 30 JOHN HALL CARTWAY YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL al 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 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 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 'tome jussila LICENSE# 131971 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑#I PARTNERSHIP ❑#I ILLC ❑# COMPANY NAME: I I ADDRESS. 184 Bog Lane, CITY (WEST HARWICH I STATE MA ZIP 102645 I TEL 1 FAX I 'CELL 15087768943 1 EMAIL Ilorneiussila(a.hotmail.com - 4. � 0' CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ! `=fir- » in *1-` , CITY-� I r � �i► MA DATE tl,o('' s Cr 3 PERMIT# APR 0 is E ,D -ESS I 0 , _4 i OWNER'S NAME/ l/ c\- 4,4P 0___ Bi('..��NG �� I� D'ESS SOJYYl� TEL FAX ys -*- OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAPRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENt>d PLANS SUBMITTED: YES 0 Netgl APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 " 9 10 11 12 13 1 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 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 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY)] 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 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT Tt} I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate t best of my knowledge `k- and that all plumbing work and installations performed under the permit issued for this application will be in com nce wi a e ' ent provision of the `` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.L z g/97I PLUMBER-GASFITTER NAME / CI -. JJ(5S)a LICENSE# SIGNATURE MP D MGF❑ Jp PJGF e1PW ❑hLPGI❑ Q0 O,,,RATION❑# c�t�PARTNERSHIP 0# LLC❑# COMPAN NAME 11 " ADDRESS U ( 80'cl4 gigue CITY thrW STATE//!P1 ZIP 0 C TEL FAX CELL5og-776 45g0 EMAIL /dr y t..ISY) 7 IO ) con')