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HomeMy WebLinkAboutBLDG-22-005068 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 14,2022 PERMIT# BLDG-22-005068 JOBSITE ADDRESS 53 WILSON RD OWNER'S NAME DUGAN TIMOTHY E G OWNER ADDRESS DUGAN MARY K 9 THE PADDOCK LAND MEDFIELD MA 02052 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL LI 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 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 RD, CITY WEST YARMOUTH STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S310N M31A321 NVId #lI1N213d $:333 ❑ ❑ 1111213d 3H1 SY S3Ai13S NOIlVOIlddV SIHl oN saA S310N N01103dSNI 1VNId AINO 3Sfl a0.103dSNI dOd 30Vd SRL S310N N01103dSNI SVO HOflO