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HomeMy WebLinkAboutBLDG-23-000304 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY 'YARMOUTH 1 MA DATE 'July 19,2022 I PERMIT# BLDG-23-000304 • JOBSITE ADDRESS 11 DANBURY ST OWNER'S NAME YOFFE SAUL D G OWNER ADDRESS [YOFFE AVIVA R 86 DRUMLIN ROAD NEWTON MA 02459 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO El FIXTURES FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 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 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 El JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME: Rustys ADDRESS. 222 Mid Tech Dr, CITY W Yarmouth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL • S310N M3IA3b NVld #lII' Bd $:33d ❑ ❑ 111%13d 3H1 Sd S3AN3S NOI1V011ddd SIHJ oN saA S310N NO1103dSNI 1VNId AINO 3Sfl?:10103dSNI bOd 3OVd SIHI S310N NO1103dSNI SYJ HOl021