Loading...
HomeMy WebLinkAboutBLDG-22-001641 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Z-11, CITY YARMOUTH MA DATE September 22,202 PERMIT# BLDG-22-001641 JOBSITE ADDRESS 12 SHERIDAN RD OWNER'S NAME RIVE GAIL P G OWNER ADDRESS C/O GAIL BASSETT 19 CAPTAIN DORE ROAD SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL El CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 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 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 ❑ 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 LICENSE# Massachusetts SIGNATURE MP 0 MGF 0 JP 0 JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Rustvs Inc ADDRESS. 222 Mid Tech Dr, CITY West Yarmouth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL