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Home My WebLink AboutBLDP-21-03408 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1� 6 CITY YARMOUTH MA DATE December 15,202( PERMIT# BLDP-21-003408 JOBSITE ADDRESS 12 WHISTLER LN OWNER'S NAME SMITH KAREN M ONEIL G OWNER ADDRESS 12 WHISTLER LN YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL 0 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 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 ❑ 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 0 JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: LORNE B JUSSILA ADDRESS. PO BOX 131, CITY WEST HARWICH STATE MA ZIP 026710131 TEL FAX CELL EMAIL lornejussila(a�hotmail.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES 1:; ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK l'=-`Y CITY: MA. DATEL:eCI4 LAC PERMIT# b i #.. -21'Cb3i D r� CO JOBSITE ADDRESS:/ h/:C 7( r, i', ;/fF OWNER'S NAME: X ?1 A4 ( /4 T/ GOWNER ADDRESS: TEI 7/77 j?< 4' FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL% PT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENTS. PLANS SUBMITTED: YES❑ NO' APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 _BOILER BOOSTER I 1 CONVERSION BURNER _COOK STOVE DIRECT VENT HEATER DRYER I FIREPLACE FRYOLATOR T FURNACE GENERATOR GRILLE �} INFRARED HEATER 013 LABORATORY COCK MAKEUP AIR UNIT rJ OVEN J ` POOL HEATER ROOM!SPACE HEATER J ROOF TOP UNIT fi TEST UNIT HEATER r.0 UNVENTED ROOM HEATER WATER HEATER I ' I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 VESA. NO ❑ If you have 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 ❑ AGENT E i SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to th s f my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be In mpllan ertinent provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. PLUMBERJGASFITTER NAM 6 ied T ' --LICENSE#V% 7/ S ATURE COMPANY NAMF,,Wr Vi"r 1,t//Q.1:— ADDRESS: 1 r ' ea , ' CITY: .r.��C^J!L/� /j /y 1- v Y STATE: /ti ZIP: FAX: .. - TEL: DELL �� )7 u 1C _ fY.� EMAIL:4rint%,\>;S.fJ�.^ 0)4, I•y'C7►Ll rr>n ) MASTER❑ JOURNEYMAN' LP INSTALLER ElCORPORATION❑# PARTNERSHIP E]# t [IC[]# i E h9.9/L ADLrre ss : t