HomeMy WebLinkAboutBLDG-17-000754 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
11K-- CITY `W.YARMOUTHMA DATE 08/05/2016 iPERMIT# f'^/y coo7Sc/
JOBSITE ADDRESS 2 SANDY LANE 'OWNERS NAME i STEVE RHODES G —
i.• OWNER ADDRESS Same f TEL--817-893-1371 uJFAX i
TYPE OROCCUPANCY TYPE COMMERCIAL''_g EDUCATIONAL L„ RESIDENTIAL_H
PRINT
CLEARLY -`
NEW::--4 RENOVATION: I REPLACEMENT:�%I PLANS SUBMITTED: YES _ NO
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR , i .
FURNACE
GENERATOR
GRILLE
INFRARED HEATER i
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN ,
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
_.. ".
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER __.._ 1 ,
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _t`NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY '-,%E OTHER TYPE INDEMNITY --I BOND Li
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 _-i AGENT t_'
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. 6611/A- nod /�1G�—
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PLUMBER-GASFITTER NAME Frank Roderick I LICENSE# 7794 - SIGNATURE
MP _.1 MGF i JP`m? JGF f LPG'. t CORPORATION =#.17627C ___J PARTNERSHIP _ '# -_» , I.LLC- `# _ .
COMPANY NAME Rus s Inc i ADDRESS 222 Mid Tech Drive
CITY West Yarmouth i STATE MA IZIP 02673 TEL 50 -Z7-51303
1 rd El IVIED:
FAX 508-771-9310 ;CELL" ' `EMAIL'SELWOOD@RUSTYSINC.COM - 't ''
,/ AUG1I2016
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