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HomeMy WebLinkAboutBLDG-21-007000 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE June 03,2021 PERMIT# BLDG-21-007000 ►f_ JOBSITE ADDRESS 317&319 CAMP ST OWNER'S NAME HARWICH ECUMENICAL CNCL FOR THE HOME G OWNER ADDRESS P 0 BOX 86 WEST HARWICH MA 02671 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 GRILLE INFRARED HEATER • LABORATORY COCKS - MAKEUP AIR UNIT - OVEN POOL HEATER ROOM/SPACE HEATER • ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER • - • WATER HEATER OTHER 1 OTHER DESCRIPTION:GAS LINE REPAIR 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# 4379 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RUSTY'S INC ADDRESS. 222 MID TECH DR, CITY WEST YARMOUTH STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S310N M3IA3?J NVId #111%13d $:33d ❑ ❑ 11161213d 3H1 SV SSA83S NOI1VOIlddV SIH1 ON seA S310N NO1103dSNI 1VNId AINO 3Sfl NO103dSNI 210d 3OVd SIHl S31ON N01103dSNI SVJ HJl021