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HomeMy WebLinkAboutBLDG-22-001342 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f LCITY YARMOUTH f MA DATE September 08,202 PERMIT# JOBSITE ADDRESS 7 HIALEAH AVE OWNER'S NAME HARRISON MARY CAROLSBLDG A22-001342 G OWNER ADDRESS 7 HIALEAH AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL lil PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 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 0 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 0 MGF © JP 0 JGF 0 LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC 0# COMPANY NAME: RUSTYS INC ADDRESS. 222 MID TECH DR, CITY W YARMOUTH STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S310N M31A321 NYld #111N213d $:33d ❑ ❑ 1I01213d 3H1 SV S3A213S NOI1v011ddV SIH. ON SaA S310N NO1103dSNI 1VNId A1N0 3Sl 210103dSNl 210d 3OVd SIH! S310N NO1103dSNI SVO H0l021