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HomeMy WebLinkAboutBLDG-23-005309 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q't CITY YARMOUTH MA DATE March 28,2023 PERMIT# BLDG 23 005309 JOBSITE ADDRESS 7 CURVE HILL RD OWNER'S NAME HAGUE MICHELLE M TRS G OWNER ADDRESS HAGUE THOMAS F III TRS P 0 BOX 1394 ORLEANS MA 02653 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ID PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO El 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 1 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 El 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 IMICHAEL HANSEN I LICENSE# 115906 SIGNATURE MP 0 MGF © JP 0 JGF❑ LPG' 0 CORPORATION❑#I PARTNERSHIP ❑# Lc ❑# COMPANY NAME: IRUSTYS INC ADDRESS. 1222 MID TECH DR, CITY IW YARMOUTH STATE MA ZIP 1026730000 I TEL 15087751303 FAX 1 CELL 1 EMAIL 1 1