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HomeMy WebLinkAboutBLDG-22-002971 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kb,,, ti 4 CITY `YARMOUTH MA DATE November 22,2021 PERMIT# BLDG-22-002971 JOBSITE ADDRESS 3 CHECKERBERRY LN OWNER'S NAME IALBERS KIRSTEN G OWNER ADDRESS 3 CHECKERBERRY LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO El FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 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 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 0 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 (MICHAEL HANSEN LICENSE# 15906 SIGNATURE MP 0 MGF © JP 0 JGF 0 LPG` 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: IRUSTYS INC ADDRESS. 222 MID TECH DR, CITY 1W YARMOUTH STATE MA ZIP 02673 TEL 15087751303 FAX CELL EMAIL 1 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE:$ PERMIT# PLAN REVIEW NOTES