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HomeMy WebLinkAboutBLDG-22-003579 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK k''7±— -7-.i CITY YARMOUTH MA DATE December 28,202' PERMIT# BLDG 22 003579 ,•,.ft____, JOBSITE ADDRESS 150 ANSEL HALLET RD OWNER'S NAME THE 150 ANSEL HALLET RD LLC G OWNER ADDRESS 277 SOUTH SEA AVE WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 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 El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 BOND 0 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 I LICENSE# (Massachusetts I SIGNATURE MP 0 MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑#I I PARTNERSHIP 0# LLC ❑#I I COMPANY NAME: IRUSTYS INC I ADDRESS. 1222 Mid Tech Dr, CITY W.Yarmouth 'STATE IMA I ZIP 102673 I TEL 15087751303 FAX 1 1 CELL 1 I EMAIL 1 S310N MIA NVId #1I1Na3d $:333 ❑ 1IV H d 3H1 SV S9A233S NOI1VOIlddV SIH1 oN saA 9310N N01103dSNI 1VNId AINO 3Sf180103dSNI HOd a0Vd SIHl S310N N01103dSNI SVO H000a