HomeMy WebLinkAboutBLDG-19-002683 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FING WORK
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;.=:Lia, ' CITY WestYarnrolM MA DATE 10/18/18 PERMIT*/91-0b/9-c0o76u83
(JO JOBS1TE ADDRESS 19 Jacqueline Code OWNER'S NAME Krnball
GOWNER ADDRESS 17 ftrmmbod Rd,E Hampton,07-06424 TEll880.759.0552 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:a '77(r f&13i.AN$SUB�4TTED: YES❑ NO❑+
APPLIANCES 1 FLOORS-4 BSM 1 2 3 i 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER -' I
CONVERSION BURNER • i ....-
COOKS
DIRECT VENT VENTHEATER i t _
• DRYER �. ��.
FIREPLACE
FRYOLATOR , ^ - -
FURNACE -.�. _Jr- y..-- MM. ..,
GENERATOR
GRILLE . _ I .
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOLHEATER
ROOM/SPACE HEATER
ROOF TOP UNR
TEST
UNIT HEATER i
UNVENTED ROOM HEATER '
WATER
OTHER HEATER i , ' 1
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL CIL.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE IHDICATETIE TYPE OF COVERAGE BY CHECIONG THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVEit I am aware that the licensee does not have the hmurmm.e 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
1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and aaurate to the best of my knowledge
and that al pkmbi g work and installations performed under the permit issued for this application wil be in axnplance with al Pertinent provision of the
Massachusetts State Pkanbirg Code and Chapter 142 of the General Laws. �7 _L Roared
PLUMBER-GASETTTER NAME Frank Roderick LICENSE# 7794 I T�'�SIIGNATURE
MP Q IGF❑ JP p JGF❑ LPG!❑ CORPORATION Q# 1762-C PARTNERSHIP❑# LLC❑#
COMPANY NAME Rush's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth • I STATE MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 cat EMAIL mburke@rustysincmm
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