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HomeMy WebLinkAboutBLDG-22-004426 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE February 09,2022 PERMIT A BLDG-22-004426 JOBSITE ADDRESS 68 WINDJAMMER LN OWNER'S NAME MMCPARTLAN PATRICK A G OWNER ADDRESS MCPARTLAN ELLEN A 68 WINDJAMMER LN SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑ FIXTURES FLOORS—s 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 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 0 JP❑ JGF 0 LPGI ❑ CORPORATION 0# PARTNERSHIP ❑# LLC 0# COMPANY NAME: RUSTYS INC ADDRESS. 222 Mid Tech Dr, CITY West Yarmouth STATE MA ZIP 02673 TEL 15087751303 FAX CELL EMAIL I • . ION MIA NVld #1IWb3d $:33d ❑ El 111Ab3d 3H1 SV S3A13S NOI1d0IlddV SIHI oN saA S310N NO1103dSNI 1VNld AlNO 3S(1 b0103dSNI 210d ROVd SIH1 8310N NO1103dSNI SY9 H9110b