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Home My WebLink AboutBLDG-22-001437 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �' CITY YARMOUTH MA DATE (September 13,2021 PERMIT# BLDG-22-001437 JOBSITE ADDRESS 59 PARK AVE OWNERS NAME KEVORKIAN LEONA TR G OWNER ADDRESS HIGHLAND FIFTEEN RLTY TRUST 125 COOLIDGE AVE UNIT 303 WATERTOWN MA TEL I 02472 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 OTHER DESCRIPTION:gas 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 LIABILITY INSURANCE POLICY❑ OTHER OF INDEMNITY El BOND ❑ OWNERS 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 Jimmie St Pierre LICENSE# 16644 SIGNATURE MP❑MGF❑JP❑ JGF❑ LPG! El CORPORATION❑# PARTNERSHIP ❑#L LLC❑# COMPANY NAME: JIMMIE W ST PIERRE ADDRESS, PO BOX 1232, CITY SOUTH DENNIS STATE MA ZIP 026601232 TEL FAX I I CELL EMAIL S310N NVld #iJ1/11?d3d $ :33d ❑ ❑ 1IWb3d 3H1.SV S3AN3S NOI1HOIlddv SIHI oN seA S310N N01103dSNI 1VNId /ONO 3Sf H0103dSNl HOd 3DVd SIHL S310N N01103dSNI SVO HDflO r ' G, ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK R -kr.F u TV E—D— ,`In'� J� YP �n0kIA GATE P._RMIT# „ ��. � 3 SEP 13 2O21Jo SITE ADDRESS '9 to r K ( i/ OWNER'S N.AME�-� � _. G , REF ADDRESS S��lj� ,(7 OWNER'S �j D - ?77j-73 73X YET F UCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL k CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 1 PLANS SUBMITTED: YES❑ NO R APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 ° 9 10 11 12 13 I 14 BOILER BOOSTER i CONVERSION BURNER, COOK STOVE I DIRECT VENT HEATER DRYER, FIREPLACE l FRYDLATOR FURNACE _ GENERATOR --I GRILLE INFRARED HEATER i LABORATORY COCKS • MAKEUP AIR UNIT 1 OVEN POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST I UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER IC ' + Ic-,e -1' r31 Ir7;Tie lc _ I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements 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 ❑ 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 that my signature on this permit application waives this requirement. i e- CHECK ONE ONLY: OWNER ❑ AGENT ❑ S ., , URE OF OWP . R AGENT "!-• I hereby ce that all of the details and information I have submitted or entered regarding this application are true nd accurate to the best of knowledge `k- and that all plumbing work and installations performed under the permit issued for this application will be in c nce with all Pe ' e ovisi of the �` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# SI NA RE. MP❑ MGF[1] JP E JJPP I JGF❑ LPGI Ill CORPORATION❑# ' G 6 PARTNERSHIP❑# LLC❑# COMPANY NAME rl? ‘.---Pi e M2 7', ADDRESS S. 0 i. C.I ! J p A j D/ZY N CITY `� (..)'Sri- fir! STATErP I/ ZIP 29673 TEL JJ-q,68 S-//zf 5 FAX CELL EMAIL j<STPie('�p jiY)4Q/ /,CDr ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes N o THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT #t PLAN REVIEW NOTES