HomeMy WebLinkAboutBLDG-19-002738 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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%A r t CITY W.Yarmouth I MA DATE 10/26/18 I PERMIT#ft-Pb l9`eV)/17i
5p(�! ! JOBSITE ADDRESS,Liit —al OWNER'S NAME boqgs
V OWNER ADDRESS same TEL 508-430-1717 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONAL RESIDENTIAL0
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:U PLANS SUBMITTED: YES NO[]
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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 (]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 ❑ BOND Q
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. 7>r. 4 Rodeted
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 I SIGNATURE
MP CI MGF❑ JP❑ JGF❑ LPG]❑ CORPORATION Q# 1762-C PARTNERSHIP❑# LLC❑#
COMPANY NAME: Rusty's Inc. I ADDRESS 222 Mid-Tech Drive 1
CITY West Yarmouth I STATE MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL mburke@rustysinc.com
928841 AJ2l4
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