HomeMy WebLinkAboutBLDG-19-002821 Unit 602 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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Atte e CITY West Yarmouth MA DATE 10/31/18 PERMIT#114,019--/7-00414(
5 JOBSITE ADDRESS 1345 Camp Street it 602-gave-✓Is W auk OWNER'S NAME Charles White Management
GOWNER ADDRESS 330 Commonwealth Ave,Boston,MA 02115 TEL 617-267-1283 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL DI EDUCATIONAL RESIDENTIAL DI
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑+ PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1 • 12 13 14
BOILER I I
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CONVERSION BURNER i I
COOK STOVE I k -
DIRECT VENT HEATER I I 1 I I 1 Ili 1
DRYER I i I I
FIREPLACE I
FRYOLATOR I I Iall.111111rnjI
FURNACE 1 I 1 1 I I
GENERATOR —+
GRILLE i I I I i— i— I t [ —+
INFRARED HEATER I I 'I I I ! 1 . 1 I
LABORATORY COCKS
MAKEUP AIR UNIT i I II
OVEN I I —I i,— I 1 i —i
POOL HEATER I I
ROOM/SPACE HEATER • 1 1 I I 7-1 I i ! I ] 1 r 1
ROOF TOP UNIT I I 1 i ,— 1 I 1
TEST I + I I 1
UNIT HEATER I i i I 1 li I i I i I I i
UNVENTED ROOM HEATER I I I I 1 1 1 FI 1 + 1 1
WATER HEATER 1Wial-1111.111.11110111111111 -111S111011.111,
OTHER i 1 1 I 1 1 i
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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 Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑' 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 performed under the permit issued for this application will be in compliance with- all Pertinent_ provision of the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. cteli 4
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 I SIGNATURE
MP Q MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION Q# 1762-C PARTNERSHIP❑# LLC❑#
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
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