HomeMy WebLinkAboutBLDG-18-001132 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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?111116 CITY Yarmouth I MA DATE 8/15/2017 PERMIT# 7Ye�/g-r�7/�J2
JOBSITE ADDRESS 32 Capt Noyes Rd 'OWNER'S NAME Elroy Kingsbury I
GOWNER ADDRESS Same ITEL IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL
PRINT El RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:El PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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DRYER 1_i.=J'nI_J __ __11_1__I'__--_1_I,__I_J _1<____I 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 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q 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
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. cbteng fJ ,/
PLUMBER-GASFITTER NAME Frank Roderick I LICENSE# 7794 I SIGNATURE
MP Q MGF❑ JP❑ JGF❑ LPG]❑ CORPORATION Q# 1762-C PARTNERSHIP 0# LLC❑#
COMPANY NAME: Rusty's Inc. I ADDRESS 222 Mid-Tech Drive I
CITY West Yarmouth I STATE MA ZIP 02673 TEL 508-775-1303 I
FAX 508-771-9310 CELL EMAIL ssavery@rustysinc.com I
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