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HomeMy WebLinkAboutBLDG-22-001861 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH 1H MA DATE October 04,2021 PERMIT# BLDG-22-001861 t3 • JOBSITE ADDRESS 35 FINCH LN OWNER'S NAME SISSON DRU G OWNER ADDRESS 35 FINCH LN WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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 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❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RUSTYS INC ADDRESS. 222 MID TECH DR, CITY 1W YARMOUTH STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S31ON MIA NVId #111N213d $:33d ❑ ❑ 1IW213d 3H1 SY S3A1:I3S NOI LVOIlddV SIHl ON seA S310N NO1103dSNI 1VNId K1NO 3Sfl NO103dSNI 21Od 39Vd SIH1 S310N N01103dSNI SVO HJf1021