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HomeMy WebLinkAboutBLDG-21-000206 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE July 15,2020 PERMIT# BLDG-21-000206 JOBSITE ADDRESS 65 GRANDVIEW DR OWNERS NAME JACQUES SARKIS G OWNER ADDRESS 50 WAMSUTTA WAY WRENTHAM 02093 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 111 PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT.0 PLANS SUBMITTED:YES 0 NO FIXTURES FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE 1 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 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 0 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 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 end 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# MA SIGNATURE MP 0 MGF©JP 0 JGF 0 LPGI 0 CORPORATION❑#r PARTNERSHIP 0# LLC 0# COMPANY NAME: Rustys inc ADDRESS. 222 Mid Tech Dr, CITY West Yarmouth STATE [MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL ,- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES CA-3 + z � _ Yes No � /) / f i../ S2 THIS APPLICATION SERVES AS THE PERMIT ❑ of F j'i' -f L rr .17 FEE: $ PERMIT# /Zdi1.11 «G4 j z4 L 314o za PLAN REVIEW NOTES