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Home My WebLink AboutBLDP&G-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 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,r,=Ja CITY YARMOUTH MA DATE 12/15/20 PERMIT# BLDP-21-003408 JOBSITE ADDRESS 12 WHISTLER LN OWNERS NAME SMITH KAREN M ONEIL P OWNER ADDRESS 12 WHISTLER LN YARMOUTH PORT,MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL ❑ PRINT CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑ FIXTURES I FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING 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 TYPE 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 at 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 at Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Lorne Jussila LICENSE 3F1971 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME LORNE B JUSSILA ADDRESS PO BOX 131 CITY WEST HARWICH STATE MA ZIP 026710131 TEL FAX CELL EMAIL lornejussila@hotmail.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT ❑ ❑ FEES$ PERMIT# PLAN REVIEW NOTES .. ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 7 CITy :rt'12(%V ► C— MA DATE a(_ /7) 4c C� PERMIT# �LDP'2l 31c VV 1 ♦ j JOBSITE ADDRESS/� t.�V I I SSP.( /Th N Li OWNER'S NAME ce P ill O 642c1 I P OWNER ADDRESS Sofyrr•C / TEL6/7-77)-j. . 3FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL`Z PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ 1\10 FIXTURES Z FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM y DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN f -- --r-- -'�~' SHOWER STALLS "�" i• �` ` SERVICE/MOP SINK _ 1 TOILET _ 4 i - 1 1 URINAL • WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i • r - " ; ,i WATER PIPING _ `� OTHER �_, 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 POUCY'. OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 an accurate tot est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in oomph witty ne revision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME,4C(i4 e L`s`�ICE LICENSE#3N7) SIGNATURE MP❑ JP ORPORATION❑# PARTNERSHIP 0# LLC❑# �j �(J COMPANY NAME V t) �-Ili J►niC 0'd ,I/C ADDRESS Si 8 4711e— CITY STATE// y ZIP ��3 TE y • FAX CELL EMAIL AN 1 ' ILS A2 i. , [C 4/1 i . The Commonwealth of Massachusetts r y_„' • Ii-St Department of Industrial Accidents a =_TI il= 1 Congress Street, Suite 100 c, =:a 1= Boston, MA 02114-2017�* www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual); r flf' J►,P.5t/C., Address:S77 Bed /we_ City/State/Zip:PaS tu(k, / O M' ' Phone#: S '776 `?7V3 Are you an employer?Check the appropriate box: Type of project(required); 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction I am a sole proprietor.3r partnership and have no employees working for me in 8. ❑Remodeling y capacity.[No workers'comp.insurance required.] 3. 1 am a homeowner doingall work m elft 9. ❑Demolition ❑ ys [No workers'comp.insurance required.] 10 ❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy of this statemen may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify u er the ains d aloes of perjury that the information provided above is true and correct, Signature: n�r • Dater~ i ....2O3 �� Phone#: J 0g'f 76' < R? Official use only. Do not write in this area,to be completed by city or town official. , City or Town: Permit/License# Issuing Authority(circle one): I' 1. Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other _ Contact Person: Phone#: