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G-19-1229 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK = ti CITY YARMOUTH MA DATE [August 28,2011 PERMIT# BLDG-19-001229 /z JOBSITE ADDRESS 31 SPRINGER LN OWNER'S NAME SPITZER WILLIAM F a G—a OWNER ADDRESS SPITZER ANNETTE M 281 VEGA ROAD MARLBORO MA 01752 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:© 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 1 FIREPLACE FRYOLATOR FURNACE 1 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 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 Frank Roderick LICENSE# 1762 SIGNATURE MPO MGF❑ JP❑ JGF❑ LPGI❑ CORPORATIONW# 1762 PARTNERSHIP ❑# LLC❑# COMPANY NAME: IRUSTYS INC M 7794 J ADDRESS 222 MID TECH DRIVE, CITY YARMOUTH STATE MA ZIP 026732580 TEL FAX I CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No ... THIS APPLICATION SERVES AS THE PERMIT❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Lthiff MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK = CITY YARMOUTH MA DATE 08/21/2018 PERMIT#-Z— /99—CP /c . ? .,-.► JOBSITEADDRESS31SPRINGERLN (OWNER'S NAME SPITZER ' G OWNER ADDRESS 281 VEGA RD MARLBORO, MA 01752 1 TEL 617-686-1638 (FM r"-- TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL El RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:E:1 REPLACEMENT:Ci PLANS SUBMITTED: YES❑ NOD APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER lik BOOSTER COOK STOVE i . •• it FIREPLACE GENERATOR I'V''.- INFRARED HEATER LABORATORY COCKS '•• Eir 47-fit ROOM I•• •,SPACE •..fir f•.� UNIT „ Ile-. 018 l UNVENTED ROOM HEATER II . . . . J. + l WATER HEATER 1' i 7I°v ®if 'aratiria OTHER11111111111111111 11111.11111110t an 51111 so _ ki /1001111131111111.110111111111111 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (❑ OTHER TYPE 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. CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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. Ail �J--/- _`rC PLUMBER-GASFITTER NAME Frank Roderick —m _se_.J LICENSE# 7794 I YYrI /SIGNATT�UREE MP D MGF 0 JP❑ JGF❑ LPG'❑ CORPORATION D#[1762-C 1 PARTNERSHIP❑#I i LLC❑# COMPANY NAME: Rusty's Inc. —I ADDRESS[222 Mid-Tech Drive 1 CITY {West Yarmouth I STATE MA ZIP[02673 TEL 508-775-1303 _____I FAX 508-771-9310 CELL EMAIL mea rustysinc.com 1 0v .1/70/� pa/7 BOJ/ Ev 9 7,101 L