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HomeMy WebLinkAboutBLDG-23-005914 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ` :` CITY YARMOUTH MA DATE April 25,2023 PERMIT# BLDG-23-005914 JOBSITE ADDRESS 80 BAXTER AVE OWNER'S NAME CHECKA NEAL G OWNER ADDRESS CHECKA ERIN M 80 BAXTER AVE WEST YARMOUTH 026730000 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:ID 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 1 _ 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 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 Lome Jussila LICENSE# 31971 SIGNATURE MP❑ MGF ❑ JP© JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: LORNE B JUSSILA ADDRESS. PO BOX 131, CITY IWEST HARWICH STATE MA ZIP 026710131 TEL FAX CELL EMAIL Iomeiussila(D.hotmail.com r ► 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 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK iifff R MA DATE PE # 3 /� � Q ' _ AP 2023JO SI =ADDR S L�dx1-jam ' OWNER'S NAME AO/ ath C mui 0 4IER ADDRESS TEL FAX B R`MENT By U -_-OCCUP4NCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENTS PLANS SUBMITTED: YES❑ N0j APPLIANCES 1 FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 1; 14 BOILER BOOSTER CONVERSION BURNER _ _ COOK STOVE 1 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 I _ UNVENTED ROOM HEATER . WATER HEATER OTHER _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 14 NO 0 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,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 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 urate to th est of my knowledge `- and that all plumbing work and installations performed under the permit issued for this application will be in complian Ith all Pe ' en rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#3 j7 / SIGNATURE MP❑ MGF❑ JPIA JUN.> LPGI 0 CORPORATION 0 4 PARRNERSHIP 0# LLC 0# COMPANY NAMEA /V✓riY D r d1 J' ADDRESS /qg- CITY ()O1/VJ/G STATE` ZIP a �� TEL ✓7 - 73 FAX CELL EMAIL r. G �*1 i � p I z❑ • :o fra • w [-+ a. w • t U' rC ua t M �. . ›- _ .... .• vx Q � a � z � 0 Ur w � C o_ trs 451. • . a