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HomeMy WebLinkAboutBLDG-22-004395 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 101. CITY YARMOUTH MA DATE February 08,2022 PERMIT# BLDG-22-004395 JOBSITE ADDRESS 33 KATHARYN MICHAEL RD UNIT4 OWNER'S NAME LAZAREK ALBERT E G OWNER ADDRESS LAZAREK ELIZABETH A 33 KATHARYN MICHAEL RD C41A YARMOUTH PORT MA TEL 02675 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❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ 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# Massachusetts SIGNATURE MP❑ MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RUSTYS INC ADDRESS. 222 Mid Tech Dr, CITY W.Yarmouth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S310N M31A321 NVId #iIIJ 3d $:33d ❑ ❑ 1IIN213d 3H1 SV S3A213S NOIJVOIIddV SIHJ oN se), S310N NO1103dSNI 1VNId AINO 3Sfl a0103dSNI 210d 3OVd SIH1 S31ON NO1103dSNI SVO 1-19f102,1