HomeMy WebLinkAboutBLDG-23-005181 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
I , CITY (YARMOUTH
I MA DATE (March 21,2023 'PERMIT# BLDG-23-005181
JOBSITE ADDRESS 1879 ROUTE 6A I OWNER'S NAME IYAEGER WILLIAM H III J
G OWNER ADDRESS ILEDDY ELLEN 3409 BURGUNDY RD ALEXANDRIA VA 22303-1216 I TEL I
TYPE OR OCCUPANCY TYPE COMMERCIAL
PRINT ❑ RESIDENTIAL El
CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0
PLANS SUBMITTED: YES 0 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 1
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 0 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
MP❑ MGF IDJP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP SIGNATURE
PARTNERSHIP ❑# LLC ❑#
COMPANY NAME IRUSTYS INC
I ADDRESS. 222 MID TECH DR,
CITY W YARMOUTH
STATE MA ZIP 026730000 TEL 5087751303
FAX CELL EMAIL