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HomeMy WebLinkAboutBLDG-22-003571 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE December 28,2021 PERMIT# BLDG-22-003571 JOBSITE ADDRESS 48 PHYLLIS DR OWNERS NAME PORTER JAMES M G OWNER ADDRESS PORTER TOULA P 48 PHYLLIS DR SOUTH YARMOUTH MA 02664-1680 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL Ei 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 1 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 Q OTHER OF INDEMNITY El 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❑JP❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RUSTYS INC ADDRESS. 222 MID TECH DR. CITY W YARMOUTH STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S31ON M3IA31 NVld #.I1(1213d $ :33d 11W213d 31-11 SV S3AH S NOLLVOIldd`d SIHI oN seA S310N N01103dSNI 1VN13 A1N0 1611 H0103dSNI Od 39Vd SIHl S310N N01103dSNI SVC HJl02i