HomeMy WebLinkAboutBLDG-19-002017 _1Zx MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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tl— CITY West Yarmouth I MA DATE 10/3/18 PERMIT#,.4Q6'1?-0'C /
VP JOBSITE ADDRESS 887 Great Island Road 'OWNER'S NAME Chase
OWNER ADDRESS same TEL 508-775-0259 (FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL 0
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES❑ NOD
APPLIANCES 7 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER — ` _r___
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER —
DRYER — —
FIREPLACE
FRYOLATOR — — — — — — —
FURNACE —
GENERATOR —
GRILLE __s — '— —,—
INFRARED HEATER —� —
LABORATORY COCKS
- — —
MAKEUP AIR UNIT
OVEN
POOL HEATER � Tl��itila
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER � I Ia
IkE
HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑l 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 0 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 withall Pertinent_ provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ?loudRoc6Ft44
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 ( SIGNATURE
MP Q MGF❑ JP El JGF❑ LPG!❑ CORPORATION D# 1762-C PARTNERSHIP 0# LLC❑#MIN
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 mburke@rustysinc.com
L� 927944 41
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Q606/-- £274-5 OK
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