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Home My WebLink AboutBLDG-22-003595 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 28,202' PERMIT# BLDG-22-003595 tiff JOBSITE ADDRESS 9 ARCHIE RD OWNER'S NAME Elizabeth Sasseen G OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS > BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER • BOOSTER CONVERSION BURNER • COOK STOVE 1 DIRECT VENT HEATER DRYER 1 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 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 0 MGF 0 JP 0 JGF❑ LPG' 0 CORPORATION❑ # PARTNERSHIP 0# LLC ❑# COMPANY NAME: LORNE B JUSSILA ADDRESS. PO BOX 131, CITY WEST HARWICH STATE MA ZIP 026710131 TEL FAX CELL EMAIL lorneiussila(a hotmail.com S310N M3IA321 NVId #1IW213d $:93d ❑ ❑ 1111N3d 3H1 SY S3A?J3S NOI1vOIlddV SIHl oN SO), S31ON NO1103dSNI lYNld AlNO 3Sl 210103dSNI 210d 39Vd SIHl S31ON N011O3dSNI SV9 H9l021 -,e, J. 40 - f ASSAC;HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ...1i_ C 4 _._,y, P5r rill Cjr1 MA DATE M ,s'� 1 PERMIT # Z 7-- t C 2 3)Cm E A DDF E- S r/ //)e( C/ /cricJ OWNER'S NAME ?A L .__ 3,517e.G1 OWNER ADDRESS -�'G: r� TE VS 6r6 `�ICV y f FAX BUILDING DEPARTMENT WPF. OR PRINT )4 YPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL CLEARLYg" NEW: RENOVATION: REPLACEMENT: (i PLANS SUBMITTED: YES I_j N APPLIANCES 1 FLOORS-4 BSIv1 1 ? 3 I 5 6 7 8 9 10 11 2 1 'I 3 1 BOILER BOOSTER CONVERSION BURNER, COOK STOVE - J I DIRECT VENT HEATER (--- DRYER � ' FIREPLACE 1 _ FRYOLATOR FURNACE GENERATOR I GRILLE ' I .. I INFRARED HEATER --j LABORATORY COCKS MAKEUP AIR UNIT j OVEN i POOL HEATER ROOM / SPACE HEATER. ' ROOF TOP UNIT TEST UNIT HEATER _ - .. UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL. Ch. 142 YESA NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY $- OTHER TYPE INDEMNITY fl BOND I 1 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage requiredby Chapter 142 of the 1 Massachusetts General Laws, and that ray signature on this permit application waives this requirement. SIGNATURE OF OWNER OR, AGENTCHECK ► i'�E ONLY: OWNER AGENT El `; I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurai to the best of m and that all plumbing work and installations performed under the permit issued for this application will be in corn ance, ith Ii� y knowledge Li Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / �'' ;;a Pertinent provision of the PLUMBER-GASFITTER NAME Acre -'` �'f`t �% / '� '' '� SIGNATURE MP MGF (� JP E JGF I� LPGI E I, `� 'ORPOP��TION ❑ f PARTNERSHIP ❑ # LLC COMPAN ' NAME ,/ GS P,'u41f� : - S ! '5 ADDRESS /oiie CITY Pal _N ,( In . �J STATE l r/i1 ZIP K1 . TEL FAX CELL S O 7 r , t �71,3 EMAIL ROUGH GAS INSPE�IIQP1 NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES