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HomeMy WebLinkAboutBLDG-22-004183 yyy MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 'January 26,2022 I PERMIT# BLDG-22-004183 Ir , JOBSITE ADDRESS 5 LOOKOUT RD OWNERS NAME ARPANO MICHAEL A G OWNER ADDRESS ARPANO SHARON 5 LOOKOUT RD YARMOUTH PORT MA 02675-1015 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Q PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0 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 I 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 LABILITY INSURANCE POLICY© OTHER OF INDEMNITYE BOND ❑ OWNERS 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# 15906 SIGNATURE MP 0 MGF❑JP 0 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: Rustys Inc ADDRESS. 222 Mid Tech Dr, CITY West Yarmouth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL • S310N M3IA3H NYld #iIW2i3d $ :33d El 111,4213d 3H1 SV S3Aa3S NOI1V01lddb SIHI oN saA S310N N0I103dSNI 1VNId A1NO 3Sfl 210103dSNI 80d 30Vd SIHI S310N N01103dSNI SVO H0f102i