HomeMy WebLinkAboutBLDG-23-001409 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
� �` t CITY YARMOUTH I MA DATE September 16.202 PERMIT# BLDG-23-001409
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`' 1 JOBSITE ADDRESS 66 TANGLEWOOD DR OWNER'S NAME KOCSIS MARY M
G OWNER ADDRESS 66 TANGLEWOOD DR WEST YARMOUTH MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERC AL ❑ 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
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
_DRYER
FIREPLACE _
FRYOLATOR
FURNACE 1
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT _
TEST
— t
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
I.
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❑ MGF Q JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: oruSTYS ADDRESS. 222 Mid Tech Dr,
CITY W.Yarmouth STATE MA ZIP 02673 TEL 5087751303
FAX CELL EMAIL
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