HomeMy WebLinkAboutBLDG-19-003224 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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"—'t17 CITY West Yarmouth MA DATE 11/20/18 PERMIT#yeifp /`i-C1dtAly
$50.00 JOBSITE ADDRESS 7 McGee Street OWNER'S NAME Manchester
G OWNER ADDRESS same w Y hOFGY TEL 508-221-5757 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIALD
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CLEARLY NEW:❑ RENOVATION:® REPLACEMENT:D 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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BOOSTER I it li II IF ii 4: 1, i. I' o
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DIRECT VENT HEATER 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 0 NO ❑
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 0
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 LI
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. 7t Rodedd
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 I SIGNATURE
MP Q MGF❑ JP❑ JGF❑ LPG/❑ CORPORATION D#(1762-C I PARTNERSHIP 0#1. I LLC❑# J
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 mburkerrrustysinc.com I
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