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HomeMy WebLinkAboutBLDG-22-04887 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE March 04,2022 PERMIT# BLDG-22-004887 JOBSITE ADDRESS 2 SEMINOLE DR OWNERS NAME OLDHAM CAROL E G OWNER ADDRESS 2 SEMINOLE DR YARMOUTH PORT MA 02675 I TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 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 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 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 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# 15906 SIGNATURE MP 0 MGF Q JP 0 JGF❑ LPGI❑ CORPORATION 0# PARTNERSHIP ❑# LLC❑# COMPANY NAME: I-rustys inc I ADDRESS. 222 mid tech dr, CITY wvermouth STATE MA ZIP 02673 TEL 5087751303 FAX CELL EMAIL S310N M3IA32i NVld #1II HJd $:33d ❑ ❑ 1J11U3d 3Hl SY S3AH3S NOLLVOIlddV SIHJ oN s8A S310N NOI103dSNI IVNId AlNO 3Sl 2i0103dSNI 80d 39Vd SIHI S310N NO1103dSN1 SVO HOflOH