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HomeMy WebLinkAboutBLDG-22-002507 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 'YARMOUTH I MA DATE November 02,202'PERMIT# BLDG-22-002507 f JOBSITE ADDRESS 143 WAMPANOAG RD I OWNER'S NAME LIBRIO JO ANN G OWNER ADDRESS 43 W NORMANDY DR W HARTFORD CT 06107-1444 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 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 0 NO 0 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 at 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 I LICENSE# 15906 SIGNATURE MP❑MGF Q JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: IrusNs inc I ADDRESS. 1222 mid tech dr, CITY Iw vermouth 'STATE MA ZIP 02673 TEL I5067751303 I FAX CELL 5087751303 EMAIL S31ON M3IA3d NVId #111A1?d3d $ :33d ❑ 0 11112J3d 3H1 SV S3i1 13S NOI1VOIlddV SIH1 oN s3A S310N N01103dSNI TTNId VINO 3Sfl 80103dSNI 803 3OVd SIH1 S310NNOIl03dSNl SVJ HJnai