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HomeMy WebLinkAboutBLDG-23-000584 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH MA DATE (August 04,2022 I PERMIT# BLDG 23 000584 JOBSITE ADDRESS 11 LILY POND DR I OWNER'S NAME 'ANACLETO MARK A OWNER ADDRESS 15 BLACK LOCH DR HARWICH MA 02645 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ElRESIDENTIAL CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED:YES ❑ NO 111 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/SPACE HEATER ROOF TOP UNIT TEST 1 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 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 (MICHAEL HANSEN I LICENSE# 115906 I SIGNATURE MP❑ MGF 0 JP❑ JGF❑ LPG' ❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#I COMPANY NAME: IRUSTYS INC I ADDRESS. 1222 MID TECH DR, ICITY IW YARMOUTH ISTATE IMA I ZIP I02673 I TEL 15087751303FAXI I CELL I I EMAIL I