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HomeMy WebLinkAboutBDP&G-21-005968 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k, CITY IYARMOUTH I MA DATE 'April 15,2021 'PERMIT# BLDP-21-005968 JOBSITE ADDRESS 112 SHERIDAN RD I OWNERS NAME IRIVE GAIL P G OWNER ADDRESS IC/0 GAIL BASSETT 19 CAPTAIN DORE ROAD SOUTH YARMOUTH MA 02664 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL El CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES 0 NO ETI 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 I SPACE HEATER ROOF TOP UNIT TEST 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 © 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 IMICHAEL HANSEN I LICENSE# IMA I MP© MGF 0 JP 0 JGF 0 LPGI El CORPORATION SIGNATURE ❑#I I PARTNERSHIP ❑#' ILLC ❑#I I COMPANY NAME: IRustys Inc I ADDRESS. 14 MEETING HOUSE CIRCLE, CITY IE.SANDWICH I STATE IMA I ZIP 102673 I TEL 15087751303 FAX 15087759310 'CELL 17742634177 I EMAIL I I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i?-.l a CITY 'YARMOUTH I MA DATE I4/15/21 I PERMIT# BLDP-21-005968 JOBSITE ADDRESS 112 SHERIDAN RD I OWNER'S NAME IRIVE GAIL P P OWNER ADDRESS IC/0 GAIL BASSETT 19 CAPTAIN DORE ROAD SOUTH YARMOUTH,MA 02664 TEL TYPE OR I ( OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO FIXTURES FLOORS El BATHTUB BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14_ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER 1 WATER PIPING 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 TYPE 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'S NAME 'MICHAEL HANSEN I LICENSE1I A I SIGNATURE MP ❑ JP ❑ CORPORATION ❑# I I PARTNERSHIP ❑# I I Lc ❑# I COMPANY NAME IRustys Inc I ADDRESS 14 MEETING HOUSE CIRCLE CITY E.SANDWICH I I STATE IMA I ZIP 102673 I TEL 15087751303 FAX 15087759310 I CELL 17742634177 1 EMAIL 1