HomeMy WebLinkAboutBLDG-22-001216 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vmn BLDG-22-001216 ,.,.�, CITY YARMOUTH MA DATE September 02,202 PERMIT# JOBSITE ADDRESS 95 PHYLLIS DR OWNER'S NAME DWINELL CARROLL J G OWNER ADDRESS 95 PHYLLIS DRIVE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: 0 RENOVATION:© REPLACEMENT:0 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 I 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY CI BOND El 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 El JP❑ JGF 0 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 #111Va3d $:33d 11W213d 3H1 SV S3A?J3S NOIlV0IlddV SIHl ON saA S310N N01103dSNI 1VNId AINO 3Sf1?10103dSNI 210d 3OVd SIHl S310N N01103dSNI SVO HOflOH