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HomeMy WebLinkAboutBLDG-22-006576 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE IMay 16,2022 I PERMIT# BLDG-22-006576 1,-2, JOBSITE ADDRESS 45 WINDJAMMER LN OWNERS NAME 'BELDEN RICHARD A JR G OWNER ADDRESS BELDEN ANN MARIE 174 ERIN LN LUDLOW MA 01056 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL©' 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 © NO❑ IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY INSURANCE POLICY© OTHER OF INDEMNITY 0 BOND 0 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 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 0 MGF Q JP 0 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 I —I CELL EMAIL S310N M3IA I Ndld #±iv sd $:33d El El 111%13d 3H1 SV S3A213S NOIlV011dd`d SIHI oN saA S310N NO1103dSNI 1VNId ,LINO 3Sfl 1O103dSNI ZIOd 3EWd SIHI S310N NOI103dSNI WO HOflOd