HomeMy WebLinkAboutBLDG-19-003456 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
eilirri$ _ CITY West Yarmouth MA DATE 11/30118 PERMIT#/,�✓Ob/9'°0 l/"yfl
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$50 JOBSITE ADDRESS 300 Buck Island,Unit#C-2 OWNER'S NAME Sullivan '
GOWNER ADDRESS Same TEL 774-230-0211 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL LI EDUCATIONAL Li RESIDENTIALD
PRINT
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
BOILER —f, 1 , t. ' I 1 I t '
BOOSTER I ! f �; I ( _ .
CONVERSION BURNER N111111110111111.11111aillt 11111111111111110111011011SMNINI .
COOK STOVE € 1 "
DIRECT VENT HEATERI h I f I 1 I
DRYER t I l •..:.:, ,
FIREPLACE ; '
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FRYOLATOR Ii 4 1 t f 1
FURNACE 11 fI., 1 kl .... 1' t' I' t
GENERATOR
GRILLE 1 t I: 1 I, f f
INFRARED HEATER ..- -- ' I . -.,9.- I
LABORATORY COCKS
MAKEUP AIR UNIT +' [ I f' t
OVEN tl -. Ei I y I I f
POOL HEATER
ROOM I SPACE HEATER t, ) -9 1, I v't, t l
ROOF TOP UNIT tl I li_. l II y €
TEST i ,,' t
UNIT HEATER ®IIM
UNVENTED ROOM HEATER mI f 4, "Ill
WATER HEATER __--
OTHER _ _
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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 D NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY EI OTHER TYPE INDEMNITY [_J 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 0-
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. 7rz444 Radelae4
PLUMBER-GASFITTER NAME Frank Roderick I LICENSE# 7794 I SIGNATURE
MP 0 MGF LIJP❑ JGF El LPG]❑ CORPORATION D#11762-C I PARTNERSHIP❑#) I LLC.❑#
COMPANY NAME: Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth I STATE[1A—IZIP 02673 TEL 508-775-1303 Ii
FAX[508-771-9310 I CELL EMAIL mburkel7a,rustysinc.com
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