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HomeMy WebLinkAboutBLDG-23-000091 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ........................ rj e CITY YARMOUTH MA DATE July 07,2022 PERMIT# BLDG-23-000091 JOBSITE ADDRESS 42 ACRES AVE OWNER'S NAME LYNCH EDWARD J G OWNER ADDRESS LYNCH ARLEEN F 42 ACRES AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES D 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 GENERATOR 1 • GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT • OVEN POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 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 E JP❑ JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP 0# LLC ❑#1 COMPANY NAME: RUSTYS INC ADDRESS. 222 MID TECH DR, CITY WEST YARMOUTH STATE MA ZIP 102673 I TEL 15087751303 FAX CELL EMAIL 1 S310N M3IA32!NVId #1101213d $:33d 1111113d 3H1 SV S3\H3S N011vDllddV SIH1 oN saA S310N N01103dSNI 1VNld AINO 3Sfl a0103dSNI 2lOd 3OVd SIH1 S310N N01103dSNI SVO HOl0N