HomeMy WebLinkAboutBLDG-19-001485 S . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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rec CITY Yarmouth MA DATE 9!7118 PERMIT#, Do ft.00/4'15
JOBSITE ADDRESS 48 Suffolk road OWNER'S NAME Luke,Chantal
GOWNER ADDRESS same TEL 74-836-0898 IFAX
TYPE
PRINTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL El
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES T FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 1 I
BOOSTER — I I, I 4 =
CONVERSION BURNER I y `� a 1 y— __
COOK STOVE l
DIRECT VENT HEATER — — I — - -
DRYER L — — —_,
FIREPLACE — t
FRYOLATOR i_ ) 1—
FURNACE y — --- --
GENERATOR —=
GRILLE — 1= --- - " ` _
INFRARED HEATER — - i— —
LABORATORY COCKS LL
MAKEUPAIRUNIT — , i ,
OVEN ..POOL HEATER
r..-__ -`-==,�- __-mom
ROOM I SPACE HEATER -- _- --'
ROOF TOP UNIT I 4 __I—
TEST -- -- -
UNIT HEATER — ; — - —
UNVENTED ROOM HEATER — -- —
WATER HEATER —t — I
OTHER — —
INSURANCE COVERAGE
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 ❑ 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. 774 'Rd ,�
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 ( 7 SIGNATURE
MP❑+ MGF❑ JP p JGF❑ LPG!❑ CORPORATION El# 1762-C PARTNERSHIP❑# LLC❑#
COMPANY NAME: Rusty's Inc. (ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth ( STATE MA f ZIP 02673 )TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL mburke@rustysinc.com
926990-io
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