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HomeMy WebLinkAboutBLDG-23-000443 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE (July 27,2022 I PERMIT# BLDG-23-000443 JOBSITE ADDRESS 17 JUDAN WAY OWNER'S NAME KESHISHIAN VARTAN G OWNER ADDRESS KESHISHIAN SEDA EBRAHIMI 17 MORNINGSIDE LN LINCOLN MA 01773 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL III PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ 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 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:pipe repair 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 LABILITY 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 (James Portanova I LICENSE# 11999 SIGNATURE MP©MGF❑JP 0 JGF❑ LPG(❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IJAMES M PORTANOVA I ADDRESS. 122 NORTH RD, CITY IDENNIS PORT ISTATE MA ZIP 02639 TEL FAX I I CELL I I EMAIL IiamesportanovaOsimail.com S310N M3IA3H NV1d #LIW2i3d $:33 J ❑ ❑ 1I1112f3d 3H1 SV S3A13S NOI1v01lddv SIHJ oN SeA S310N NO1103dSNI 1VNId NINO 3Sfl O103dSNI eIOi 30'dd SIHI S310N NOI103dSNI SVO HOflO l MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '5-- 7it .•'' --, .T `'fit 1 , b � .- .._. ff4'� UJ4-`�" MA DATE 7`2 `ZZ PERMIT# 23- cyti 3 UL 2 6c16I A DR SS 11 J u a,Art -A OWNERS NAME l\�S► S�� � Bu DINGDEPARTMENT EOWNER A R SS }�``' — TEL6\7-233-b537 FAX TYPE OR___ ^A R TM E N T PRINTYFE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION REPLACEMENT: ❑ '�� REP PLANS SUBMITTED: YES❑ N0,,&11 APPLIANCES 1 FLOORS s.M 1 ? 3 4 5 6 9 to t 1 12 l BOILER __ BOOSTER i CONVERSION BURNER _ I COOK STOVE j DIRECT VENT HEATER DRYER FIREPLACE i FRYOLATOR FURNACE GENERATOR GRILLE _ ___J INFRARED HEATER --7 LABORATOR`(COCKS ____I —______I MAKEUP AIR UNIT • OVEN ; POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST ' _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I _____I OTHER �o l u cawl i°k P `A y I i �) kQL_ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of fVIGL.Ch.142 YES 0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY NECKING 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 fMaser- It• . al I. • that my signature on this permit application waives this requirement. I. CHECK ONE ONLY: OWNER E AGENT 5-' SIGNATURE OF OWNER OR AGENT 71:2 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 complian with all Pertinent provision of the �` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-c 'FITTER NAME L LICENSE# SIGNATURE MP • MGF❑ ❑ JGF❑ LPG! ❑ CORPORATION ❑If PARTNERSHIP❑# LLC ❑If COMPANY NAME 6Y-4 Gt 100(-tti-- (U j.l,r j 0 ADDRESS 2-2.-- NO r---1- S 1— CITY_ , nv 1 STATE I' 't/4- G�6 3 c 7- ZIP 3 ( TEL--� 0 :�Z6-�L17 FAX CELL EMAIL ��IJGI GASIN5P'Ei-3'IoP� 10Tg THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: PERMIT PLAN REVIEW NOTES