HomeMy WebLinkAboutBLDG-22-0002387 q� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
kr CITY YARMOUTH MA DATE October 26,2021 PERMIT# BLDG-22-002387
JOBSITE ADDRESS 16 ADAMS RD OWNER'S NAME CARBERRY MARILYN E
G OWNER ADDRESS HAROUAIL M T&GILLESPIE K 16 ADAMS RD WEST YARMOUTH MA 02673 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ 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 1
BOOSTER •
•
•
_
CONVERSION BURNER _
COOK STOVE _
DIRECT VENT HEATER _
DRYER
FIREPLACE
FRYOLATOR
•
FURNACE
GENERATOR
•
GRILLE _
INFRARED HEATER
LABORATORY COCKS _
MAKEUP AIR UNIT
•
OVEN _
POOL HEATER
ROOM l SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
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 0
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 0 MGF 0 JP 0 JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP ❑A LLC❑4
COMPANY NAME: RUSTYS INC ADDRESS. 222 MID TECH DR,
CITY WEST YARMOUTH STATE MA ZIP 02673 TEL 5087751303
FAX CELL EMAIL
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