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HomeMy WebLinkAboutBLDG-21-003941 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK € 6 CITY YARMOUTH MA DATE January 18,2021 PERMIT# BLDG 21 003941 JOBSITE ADDRESS 20 REID AVE OWNER'S NAME MESQUITA ROSILENE G G OWNER ADDRESS 20 REID AVE WEST YARMOUTH MA 02673-3530 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ElRESIDENTIAL FL CLEARLY Y NEW: ❑l RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO FIXTURES 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 1 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 I LICENSE# 'Massachusetts SIGNATURE MP❑ MGF 0 JP❑ JGF 0 LPG' 0 CORPORATION❑#I I PARTNERSHIP 0#I ILLC 0#I I COMPANY NAME: 'Rustys Inc I ADDRESS. 1222 Mid Tech Dr, CITY 'W Yarmouth I I I I I TEL 15087751303 STATE MA ZIP 02673 I FAX 15087719310 I CELL 17742634177 I EMAIL I I 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