HomeMy WebLinkAboutBLDG-18-007240 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
tits" CITY W.YARMOUTH __ - _. -_ MA DATE 06/1812018 PERMIT#, At '-/t''a '7Z ra
JOBSITE ADDRESS 1 FILLMORE RD. OWNER'S NAME LINDSAY JOHNSON
G •
OWNER ADDRESS Same TEL FAX •
TYPE OR
PRINT r OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL +
CLEARLY NEW: RENOVATION: REPLACEMENT: + PLANS SUBMITTED: YES NO +:
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 17. 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/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER - ' '
UNVENTED ROOM HEATER
WATER HEATER
OTHER BACKFLOW PREVENTER
• INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I + NO
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 complianceavith all Peiinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (_..n y /t / . L�
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 ryu „SIG/NNpATTUpRREE�(�
MP + MGF JP JGF LPGI CORPORATION + # 1762-C PARTNERSHIP # LLC ;#
COMPANY NAME: Rusty's Inc, ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth : STATE MA ZIP 02673 TEL 508-775-1303
FAX 508.771-9310 CELL ' , 'EMAIL • - ,
L461/4
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