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HomeMy WebLinkAboutBLDG-22-001334 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 CITY YARMOUTH MA DATE September 08,202 PERMIT# BLDG-22-001334 IN JOBSITE ADDRESS 405 ROUTE 6A OWNERS NAME WHITE SALLY C G OWNER ADDRESS 41 NORTH MAIN ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL El CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO 0 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 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 El 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# 115906 MP 0 MGF © JP❑ JGF 0 LPGI ❑ CORPORATION El#I I SIGNATURE PARTNERSHIP ❑#I ILLC ❑#I I COMPANY NAME: IRUATYS INC I ADDRESS. 1222 MID TECH DR, CITY IW YARMOUTH I I I ZIP I02673 I TEL 15087751303 STATE MA ( FAX I 1 CELL 1 I EMAIL I 1