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HomeMy WebLinkAboutBLDG-23-001407 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I r �/ CITY IYARMOUTH MA DATE September 16,202 PERMIT# BLDG-23-001407 JOBSITE ADDRESS 1184 SOUTH SEA AVE UNIT 13 I OWNER'S NAME 'CARROLL PAUL T G OWNER ADDRESS CARROLL SANDRA J 19 WATER ST FOXBORO MA 02035-1719 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT El CLEARLY NEW: El RENOVATION:❑ REPLACEMENT:El 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/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 El OTHER OF INDEMNITY El 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 ImICHAEL HANSEN LICENSE# 15906 SIGNATURE MP El MGF El JP❑ JGF❑ LPG' El CORPORATION El# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: IRUSTYS INC ADDRESS. 1222 MID TECH DRIVE, CITY IW YARMOUTH STATE MA ZIP 102676 I TEL 15087751303 FAX 1 CELL EMAIL