Loading...
HomeMy WebLinkAboutBLDG-22-006281 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ra CITY 'YARMOUTH I MA DATE /May 02,2022 I PERMIT# BLDG-22-006281 JOBSITE ADDRESS 503 ROUTE 28 UNIT 12 OWNER'S NAME MCCULLOUGH SHARON M G OWNER ADDRESS NEILD SHERYL L 59 ELM ST STONEHAM MA 02180-1636 TEL J TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT 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:gas piping to meter and appliance 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 El BOND ❑ OWNERS 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 it MA SIGNATURE MP❑MGF Q JP❑ JGF❑ LPG/ 0 CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: 'Rusty Inc I ADDRESS. 1222 Mid-Tech Drive, CITY IW.YARMOUTH ISTATE MA ZIP 02673 TEL 15087751303 FAX CELL EMAIL I S310N M3IA321 NTId #.11M3d $ :333 ❑ ❑ .I11b3d 3H1 SV S3AH3S NOIld3llddb SIHl oN saA SRION NOI103dSNl 1VNl3 AlNO 3Sl 21013 dSNI 2JO l 39Vd SIHI S310N NO1103dSNI SVO HOf1011