HomeMy WebLinkAboutBLDG-19-000028 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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/ PERMIT# /.-lib`n- 40a'
JOBSITE ADDRESS g) 3 CJhx`Tf s Y4 'OWNER'S NAME t ,rd nz_
GOWNER ADDRESS I Same J TEL FAX( I
TYPE OR OCCUPANCY TYPE COMMERCIAL II EDUCATIONAL 0 RESIDENTIAL[
CLEARLY NEW: RENOVATION:® REPLACEMENT:D PLANS SUBMITTED: YES 511 NOD
APPLIANCES 7 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 00111_IM Phi nNIMt
BOOSTER 1.L11.�_Mtillailltr
CONVERSION BURNER - :j�5M __ allsl.
COOK STOVE IIIMISSIMIINSSIMSSINSIIP
DIRECT VENT HEATER IIMIK]IMaifgniSSNM11.0' Jrn
DRYER S.SI SJ SS.--S.—
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FRYOLATOR 11. 111113.111 .110II _
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GENERATOR MIIIIMINNIIIIIIIE.1—r5S5NM_I. fly
GRILLE . �_-�0101111_ ii _ ]_(a `Iii'__i�
INFRARED HEATER �;��MIjMAIIIIKUNIMIIMI
LABORATORY COCKS MIIIIIIIIINOlM ____
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MAKEUP AIR UNIT SIMMEMi____
OVEN IIIINIJINIIISISIINLIMPJIIPOMSIPMMIIIIIIIIINIIIIIOISNMIIIEIIISJ
POOL HEATER MiI.s. flu �� ..p�� 1 _1111.1*
ROOM I SPACE HEATER i; �� _____IYrrIi� a �
ROOF TOP UNIT � � lM
TEST MIN,WAM'SII11110.1.0II.1 _I
UNIT HEATER IIIIIIIIIIMEIMEMJSMIONOOSJIMaill.SION
ENT,D ROOM 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 9 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY I0 BOND 9
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 0
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_•pennit Issued for this application will be I liance with a in t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Frank Roderick 1 LICENSE#'7794 � S NATURE
MP 0 MGF ED JP Q JGF® LPG(® CORPORATION 9# 1762-C I PARTNERSHIP®#—. LLC 0#=
COMPANY NAME: Rusty's Inc. 1 ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth 1 STATE FM-Al ZIP 02673 TEL j 508-775-1303 F
FAX 508-771-9310 CELL (EMAIL ssavery@rustysinc.com
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