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HomeMy WebLinkAboutG-19-2372 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ilio=c` • _"kr_I CITY West Yarmouth MA DATE 10117/18 PERMIT It fAairifl .057 . sod `l JOBSITE ADDRESS 37 Hidden Aaes Rd. OWNER'S NAME Peters t. GOWNER ADDRESS same Tal 508.394.5071 )FAX-' I TYPEOROCCUPANCY TYPE COMMERCIAL El EDUCATIONAL❑ RESIDENTIAL 0' NP CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO Q APPLIANCES) FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ( + I BOOSTER i i h i k 1 CONVERSION BURNER M COOK STOVE . { _I I. DIRECT VENT HEATER 4 DRYER r ! I 1 FIREPLACE t . FRYOLATOR • t I I t FURNACE ' 1 . / s GENERATOR GRILLE .�+�t+� INFRARED HEATER - - LABORATORY COCKS IIIII, MAKEUP AIR UNIT . IIMPAINV OVEN i .� POOL HEATER t ""' ROOM I SPACE HEATER 1 t ROOF TOP UNIT N TEST r t , UNITHEATER UNVENTED ROOM HEATER n 1 r t WATER HEATER { OTHER ,t 4 { -, P r , 1 l INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES Q NO ❑ IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY 0 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 perfomned under the permit issued for this application will be in compliance` all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'rao4 Rodead PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 I SIGNATURE MP Q MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION 0# 1762-C I PARTNERSHIP 04/ LLC❑# COMPANY NAME: Rusty's Inc I ADDRESS 222 LW-Tech Drive CITY West Yarmouth I STATE MA ZIP 02673 )TEL 508-775-1303 I FAX 508-771-9310 CELL EMAIL mburke©rustysinc.com 928583 Llel - _gifsAi 79 V? )2,0 w