HomeMy WebLinkAboutBLDG-17-001845 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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11I- CITY Yarmouth MA DATE 10/6/2016 PERMIT#M-Dr-/-7 ar�7 ��
JOBSITE ADDRESS 120 Wianno Rd OWNER'S NAME 011ie Naas
Glif; OWNER ADDRESS Same TEL (FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL DI
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:U PLANS SUBMITTED: YES❑ NOD
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I t I' I -- I .__ I _J I'_ J ' —I' - 1
BOOSTER -"—
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CONVERSION BURNER I I I _ I 1' ! 1
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COOK STOVE h_ — ) ' J __1' _—_1' I' __- ' _._ f' _I __I ---- I _t
DIRECT VENT HEATER _I _If _ I' ('y I'—i'y_ IL—,-_ ' I I° t �IL�r L1._ l 1
DRYER TI'—t'�I'-1'—�=--1'—I'• . , Il—=1l !=--1'= a%---JI:-1
FIREPLACE I I I I I I _I _I,_1 _I _J tI.,'_I
FRYOLATOR 1_, I _ _ _ �I'_.
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FURNACE ' —1 'iI 1 I I Ji J _I t _I —$1 l' I
GENERATOR ' _I_l _I _I ! _J' I _I_I_I'_ -__J _ I
GRILLE �Itf I I' I I I 1.,__:-J'. _ . I'J-.___J _I. 11TIi__J
INFRARED HEATER I I 1I I, I 1 l' I' -1' I ,_1- I' I --1
LABORATORY COCKS _I• I ( � I I I ) 1 I 1 l 1___1 I ,l
MAKEUP AIR UNIT . 1 '-'�''' ;r— I _"11 I _ _ I_ - 1 -_
OVEN Is I I!...,,- I.'�.... 1 s. _±.� I ._ II I 1 � ., 1 ._ I' a1 I' , L,.I
POOL HEATER __I'�.—i• ,W I—�-1 s-r-rI - .,r I „ Tl anal -��I _ I _ I j Id_-1 ._ .I
ROOM/SPACE HEATER —J 1 __.-J'.a._,J'_._ I TI ____I Irl _._J' ,I' t'_--J __ ,.,I'..__.I
ROOF TOP UNIT I I' It_ 1 1 i 1—- d—
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TEST J - if I - --I _ 1 I _I - -J -- J -___1 - I _ I - _ I'' . 1
UNIT HEATER I' - I' i l I I _ _ —1'' I J
UNVENTED ROOM HEATER 1 I _! 1' I _I_I'�I'_J
WATER HEATER - 1 _J _ I 1 1 _ 3 ,�1
OTHER I Cut and cap gas pipes t 1 ) _— ME 1 _ ' 1
II I ' :ll _.. 'r 1 l _�.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 El 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 ❑
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 wi c mpliancQ with rtinent provisipn of the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ., , //�' / . J, Dl
PLUMBER-GASFITTER NAME Frank Roderick (LICENSE# 7794 lKKK��000 SIG ATURE
MP 0 MGF❑ JP❑ JGF D LPGI❑ CORPORATION Q# 1762-C PARTNERSHIP:1# 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 ssavery@rustysinc.com
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