Loading...
HomeMy WebLinkAboutBLDG-22-002386 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e CITY YARMOUTH MA DATE October 26,2021 PERMIT# BLDG-22-002386 ti JOBSITE ADDRESS 76 LUMBERJACK TRAIL OWNER'S NAME BECRELIS NICHOLAS N G OWNER ADDRESS BECRELIS ATHENA N 76 LUMBERJACK TRAIL WEST YARMOUTH MA 02673 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL ❑ 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 1 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 • 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❑ 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 LICENSE# 15906 SIGNATURE MP❑ MGF 0 JP❑ JGF 0 LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC Cl# COMPANY NAME: RUSTYS INC ADDRESS. 222 MID TECH DR, CITY WEST YARMOUTH STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S310N M3IA3a NVId #11wa3d $a3d El ❑ 11W0,13d 3H1 SV S3Ad3S NOIJVOIlddV SIHl oN saA S310N N01103dSNI 1VNId AlNO 3Sfl a0133dSNI HOd 30Vd SIHl S310N N01103dSNI SVO HJflOa