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Home My WebLink AboutBLDG-23-002905 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e1- CITY YARMOUTH MA DATE November 28,202; PERMIT# BLDG-23-002905 JOBSITE ADDRESS 378 ROUTE 6A OWNER'S NAME MUSANTE NEIL E G OWNER ADDRESS MUSANTE CYNTHIA J 8 KESWICK ST APT 5 BOSTON MA 02215-3758 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:D 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 1 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 El 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 El JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: ADDRESS. 84 Bog Lane, CITY WEST HARWICH STATE MA ZIP 02645 TEL FAX CELL 5087768943 EMAIL lorneiussila(a•hotmail.com ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t, M _1 � , 'IL ,IL IA•v I C IAA DATE /_/�� li ; 40V 2&2922-E' .DDP'•E•SS tG f l AI Oc�,t way c v� L. ,�-1—f OWNER'S NAMEr/�C1V) t� NG OWNERa�DFIESS J '14�''_ • R�' PARTn2ENT TELC��'_77h-Dajt� FAX PRINT `` "==� _Y:TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO . BOILER -f FLOORS.- s`M 1111111/111.111MIIIMMIIIERIMMIEll BOOSTER 13 14 CONVERSION BURNER __ COOK STOVE __WI DIRECT VENT HEATER - DRYERIIIII FIREPLACE FRYOLATOR I FURNACE - G GENERATOR �_ -_ - INFRARED HEATER LABORATORY COCKS ___ MAKEUP AIR UNIT — OVEN POOL HEATER - ROOM/SPACE HEATER ROOF TOP UNIT __________________MI IIIII TESTIn UNIT HEATER UNVENTED ROOM HEATER WATER HEATER Ill il I I la I in..•m n..1 I Inn.m...•m_____________ — OTHER ______________ 111111.111111111 - GE I have a current liabiii insurance policy or its substantial eIquivalent v nt which SURANCE 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 Ni OTHER TYPE INDEMNITY ❑ BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insuurance coverage required ❑ Massachusetts Gc-:ric.ral Laws,and that my signature on this permit application valves this requirement. � r€ d by Chapter 142 of the q tk. .-N SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 'th I hereby certify that all the details and information I have submitted or entered regardingthis AGENT and that alle certify th toft P plumbing and installations performed under the permit issued for this application will be in coo lianc� • Massachusetts State Plumbing Code application are true and accurate to th b `> g and Chapter'142 of the� NP t of my knowledge general Laws. P ith all Pe.'- i provision of the PLUMBER-GASFITTER NAME,/orh�--r' .i1� / LICE MP � MGF❑ LICENSE#3197/ JGF❑ LPGI SIGNATURE COMPANY NAME ❑ CORPORATION ❑# �� j �� J —� PA,RTI<�RSHIP trh✓irk LLC❑ : CITY g( „/� ADDRESS ! ,I� F STATE �_��ZIP CELL TEL 5 2g'7J6 89�13 EMAIL