HomeMy WebLinkAboutG-19-1056 �( I
_L\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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,,ttom�� pItlCITY West Yarmouth ( MA DATE 08/14/2018 PERMIT#/.�fJ'�y-0O/oS
JOBSITE ADDRESS 191 Mid-Tech Dr (OWNER'S NAME Spinal Technology (
GOWNER ADDRESS Same (TEL 508-989-4866 (FAXI — 1
TYPE OR OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL 9 RESIDENTIALQ
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CLEARLY NEW:❑ RENOVATION:9 REPLACEMENT:E] PLANS SUBMITTED: YES 9 NO a
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER # —,I 1
BOOSTERII Ii I
CONVERSION BURNER - ._4' . _ _.I u ; ,_:==;- .:—
COOK STOVE t - �, _ y _ 0 fl ii Nl _I .4Y
DIRECT VENT HEATER :
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DRYER s si 11 it _dl n II II it I! I t,
FIREPLACE
FRYOLATORUI __
FURNACE r t. f r r' it 11 - iii II
I 1 mi GENERATOR �_.
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GRILLE , ii , , - i ,..,:1 . ".'- - ---:1 , - •
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INFRARED HEATER Ri. _.: . .,ll 1 _ l, -- 1 - II
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LABORATORY COCKS i 1 t
MAKEUP AIR UNIT
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POOL HEATER ri R' di H ri I H 11 d' I .
ROOM ISPACE HEATERI. ta I it i SIF 1- of
ROOF TOP UNIT Ii
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TEST
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UNIT HEATER 1 a I i I I ll I'
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TED ROOM HEATER �� � ��
OTHER
WATER HEATER � '
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Cf OTHER TYPE INDEMNITY 0 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.
CHECK ONE ONLY: OWNER 0 AGENT Li
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. % Nd /O c `Gk_
PLUMBER-GASFITTER NAME Frank Roderick I LICENSE# 7794 SIGNATURE
MP Eti MGF 0 JP❑ JGF 9 LPGI 0 CORPORATION E# 1762-C-1 PARTNERSHIP®# LLC 0# l
COMPANY NAME: Rus y Inc. (ADDRESS 222 Mid-Tech Drive g
CITY West Yarmouth —1 STATE ral ZIP02673` "+ G TEL X505 775-230_ J 7
FAX 508-771-9310 CELL EMAIL'pneary@rustysinc.com ('---�
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