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HomeMy WebLinkAboutBLDG-22-006419 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V---:1411"1 CITY YARMOUTH MA DATE May 06,2022 PERMIT# BLDG-22-006419 JOBSITE ADDRESS 124 GERMAN HILL RD OWNER'S NAME TOWN OF YARMOUTH G OWNER ADDRESS WATER DEPT 1146 ROUTE 28 SOUTH YARMOUTH MA 02664-4463 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS BSM 1 2 3 r 4 5 6 7 8 r 9 10 11 12 r 13 r 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# 15906 SIGNATURE MP❑ MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: Rustys Inc ADDRESS. 222 Mid Tech Dr, CITY W Yarmouuth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S310N M3IA32i NVld #111A1b3d $,33d ❑ ❑ 11141b3d 3H1 SV S3A0,13S NOI1VOIlddV SIHI oN S8) S310N NO1103dSNI-VNld AINO 3Sfl N0103dSNI 210d 30Vd SIHI S310N N01103dSNl SVO HOfON