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Home My WebLink AboutBLDG-22-04905 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ��TA� � CITY YARMOUTH MA DATE March 07,2022 PERMIT# BLDG-22-004905 >P -`' JOBSITE ADDRESS 212 KATES PATH VILLAGE OWNER'S NAME HIGGINS ANNE H G OWNER ADDRESS 212 KATES PATH YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ 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/SPACE HEATER ROOF TOP UNIT - TEST _ _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 2 OTHER DESCRIPTION:repair gas pipe 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❑ 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 lorne jussila LICENSE# 31971 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 84 Bog Lane, CITY Harwich STATE MA ZIP 02645 TEL FAX CELL 5087768943 EMAIL S310N M31A3H NVId #11012nd $ 333 ❑ ❑ 111Al213d 3H1 SV S3A83S NOIlVOIlddV SIHl ON s8A S310N NO1103dSNI 1VNId AINO 3Sf1 N0103dSNI 210d 3OVd SIH1 S310N NO1103dSNI SVO HOfOd — D ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F. -"'_ CI Y h�, DATE PPERMIT2 _�U�1 j 7 J B' E ADDRESS i 6) p.,5 n I o7�� .a 3� OWNER'S NAME - //�J BUIL ING, .)L ART ENT ) _.. _OWJ R.ADDRESS SG1YY1 L ��',-,_5.,-,_5. S L.,� O � By TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ EDUCATIONAL D RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT S PLAN� c„UBMITTED: IES❑ N0� APPLIANCES-1 FLOORS-4 BCha 1 2 3 1 5 I 6 BOILER ° 9 10 11 12 1^ BOOSTER CONVERSION BURNER COOK STOVE DIRECT EVENT HEATER 1 DRYER J �_ 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 LINVENTED ROOM HEATER • WATER HEATER ______r__ OTHER J_Ci)s . ___,___L____ SiU� nT 6r --L— Inors INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES'-,{6 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY El 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. SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER ❑ AGENT El ` I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurat 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 ' ce wi e ent provision of the � 9 Massachusetts State Plumbing Code and Chapter 142 the General Laws. Ql o# PLUMBER-GASFITTER NAME JOrhe fs>/c- LICENSE 'CCI �S jcj7/ SIGNATURE MP ❑ MGF❑ JP151 JGI2p1 L GI y h (-:,),_!RP oRATIoN❑It PARTNERSHIP❑* LLC❑# COMPANY NAME/ v t))#'2 Jr Or. S 1. > ADDRESS ifYte Cy /7j CITY f Wl C/'• STATE///A ZIP (1)...6 TEL J TEL S ' /, Y3 FAX )) CELL 5:/fi�''>c EMAIL die C'4 a/ Cc VI • ROUGH GAS I �P'Ed '1W(O` ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT [^ PEE: $ PERMIT 0 PLAN REVIEW NOTES