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HomeMy WebLinkAboutG-14-433 • • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ®r`-a� 1 CITY (WEST YARMOUTH MA DATE 1111/2013 PERMIT# 22/9.1— Y33 • C s 6 - `� JOBSITE ADDRESS r23 Sioux Road --(OWNER'S NAME Francis Berlo GOWNER ADDRESS 54 Stonegate Drive E.Bridgewater,MA 02333 I TEL 617-694-8476 FAX 1 TPRINT OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL[ RESIDENTIAL LA CLEARLY NEW:❑ RENOVATION:C! REPLACEMENT:[A PLANS SUBMITTED: YES[ NOD .4\ APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER '_____J I .._._I _I___.J1 —.1:_.:I ....._.J.._.1. 11......1......J_ I _.J BOOSTER CONVERSION BURNER ..,,,. 1 ,,,r .J --,.,_I „I_. .J' 1.. 1'......._.1 „J ,_,,4 f 1; 1' I._,�-_J COOK STOVE J _. 1 .. I ��'_ DIRECT VENT HEATER .,___l1 ......„1.1.,__I __ ..1'. _ J _,_,..1 _,..I,,..1c.1 _.,„.,. I 1 1 ______1,______I DRYER _ J FIREPLACE .. x I 1 .,..,___I ,______Iii, I ______1,____J . ._._..J J J . I ...7_1 . .._J _,._.I FRYOLATOR ,....._J 1 ...,..-J _,___J______.1 .„J .,...._._.1,..... ..7 J --_r-1_ -1 ._._.J .1 FURNACE 1 . 1 .J _r 1 ..I ., I .. ._.l _. ..I _J I ' .,_ _.I GENERATOR I _ Imo' ...._ J .. . _.I ' GRILLE I I _. J . f______1` __I „J aJ _ -1 { —1 1,_____J INFRARED HEATER .,.. I LABORATORY COCKS _,r!_____.1 -- I _I ,_..___} J' ._ I I_.. .,1",__e MAKEUP AIR UNIT 1J. J .1'.,-...3....___t__ 1 „,,,,;„,j,. f . _ I' I _ _.._.1 OVEN _I':.. I I _ F ..r..J .-J ' I POOL HEATER .._ I._.._..I , I-, ._I'.._._._JI___I ____I __._.J .,x„__,1..._..1._., J ...l .._ , f __...._.I ROOM I SPACE HEATER e .1__..._ i i 1,.._„,_,JL, r_ .1 __ I_; ...1 I _ J' ROOF TOP UNIT 1 I _ I 1'__ I . I 1 I 1 TEST J .. J I I I I rJ_....,, 1 1 . UNIT HEATER I . 1 1 i . _ .. . _ . ... 1 I ___ '. -TED •e�� :R UNVEN E p_.. t_.1.=.111=====''�� rnlitgi LIiI1 . J I II alb X11 __ 1 1 a �jo�� ��gp�fi'MEN7 INSURANCE COVERAGE 1=u7(afi4i( lnurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q 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 0 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 0 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 comp! nce with all Pertin t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Frank W.Roderick 1 LICENSE#�7794 I SIGNATURE MP aiMGF❑ JP© JGF 0 LPGI 0 CORPORATION # 1762-C `PARTNERSHIP 041 I LLC[!#r r--1 COMPANY NAME:�Rusty's Inc. ----1 ADDRESS 222 Mid-Tech Drive I CITY West Yarnouth 1 STATE I,r MA I ZIP(02673TEL 508-775-1303 --FAX 508-771-9310 I CELL EMAIL — _1