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HomeMy WebLinkAboutBLDG-21-007287 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �q BLDG 21 007287 11/4, , 1 CITY YARMOUTH_, MA DATE June 15,2021 PERMIT# Li r s JOBSITE ADDRESS 10 GLENWOOD ST OWNER'S NAME PETERSON JANICE M TRS G OWNER ADDRESS PETERSON RICHARD E TRS 10 GLENWOOD ST WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 111 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 1 , FRYOLATOR • FURNACE , 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# Massachusetts SIGNATURE MP❑ MGF Q JP❑ JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: Rustys Inc ADDRESS. 222 Mid Tech Dr, CITY West Yarmouth STATE MA ZIP 02673 TEL 5087751303 FAX 5087719310 CELL 5089580277 EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE:$ PERMIT# PLAN REVIEW NOTES