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HomeMy WebLinkAboutBLDG-22-003479 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' e CITY YARMOUTH MA DATE 'December 21,2021 PERMIT# BLDG-22-003479 JOBSITE ADDRESS 128 WILSON RD I OWNERS NAME LAPSLEY FELICITY A G OWNER ADDRESS GIRELLI RONALD A 28 WILSON RD WEST YARMOUTH MA 02673 TEL I _ _ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0 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 I 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 LICENSE E 15906 SIGNATURE MP 0 MGF Q JP❑ JGF 0 LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RUSTYS INC ADDRESS, 222 MID TECH DR, CITY W YARMOUTH STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S3lON MIA NVld #JI1A1H3d $ 33H iIW0:13d 3H1 SV S3A 3S NOl1V011ddd SIHI oN sei S310N NOIlOdSNI 1VNId AINO 3Sf1 H0103dSNl HOd 3OVd SIN! S310N NOIl03dSNl SVO H0f10H