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HomeMy WebLinkAboutBLDG-22-005110 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r/ CITY [YARMOUTH 1 MA DATE March 15,2022 PERMIT# BLDG-22-005110 r JOBSITE ADDRESS 46 PINE ST OWNER'S NAME SLOVENKAI MARGARET A G OWNER ADDRESS 46 PINE ST YARMOUTH PORT MA 02675 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT❑ PLANS SUBMITTED:YES❑ NO El 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❑ 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 I LICENSE# Massachusetts SIGNATURE MP 0 MGF Q JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME 'Rush's Inc I ADDRESS. 1222 Mid Tech Dr, CITY IW.Yarmouth I STATE MA ZIP 02673 TEL 15087751303 FAX CELL I I EMAIL I S310N M3IA32:1 Ndld #lIW2i3d $:33d El 1I11213d 3H1 SV S9A S NOI1V3IlddV SIR! ON Sal S310N NOI103dSNI 1VNIU AINO 3Sfl IO103dSNI 2I03 39Vd SIR! S31ON NO1103dSNI S` D HOflO