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i SI\ ''MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING •
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-tl (Print Type) 01)1-4 241
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u , Mass. Date • 13-� 7 2<1 yG Permit # `-fT]
'` 4 Building Location //17-/.57 ( EAVfrled Ave. Owner's Name reebeetck (Un1L.UN
• ,_• 30e1T1+ 4,42 noiJl l•f Type of Occupancy 1-gt=SI DEnrTi AL-
(village)
New ❑ Renovation 0 Replacement ❑ • Plans Submitted: Ye - - •
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" _ AUG 18 READ
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SUB—HSMT.
•
BASEMENT
t 1ST FLOOR _ .
Mi
END FLOOR ' _
` DRD FLOOR
4TH FLOOR J"acEPIEU de ..
z. . 57M FLOOR , "1 ,
6714 FLOOR
7TH FLOOR ...
5TH FLOOR •
Installing Company Name Rusty' s Inc. •'Check one: •Certificate
Address 222 Mid-Tech Drivel, Corporation 1762-C '
• West Yarmouth O. partnership . •
Business Telephone 508-775-1103 0 Firm/Co.
Name of Licensed Plumber or•Gas Fitter Frank W. Roderick ,
INSURANCE COVERAGE: •
• I have a our; n liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. . ,
Yes No ❑
It you have,c coked lel, please Indicate the type coverage by checking the appropriate box.
A liability Insurance policy . Other type of 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 Mass. General Laws, and that my signature on this permit application waives this requirement.'
Check one:
• Owner❑ Agent 0
Signature of Owner or Owner's Agent
I hereby Betty that all of the details and information I have submitted (or entered)in above application are true and acuate to the best of my
•knowledge and that all plumbing work and installations performed under the permit issued for this appicatlen will be in compliance with all _
pertinent provisions of the Massachusetts State,Gas Code and Ohapter 142 of th neral laws i - ' t 1 1 . I t 1
By _, -- T OI Ucensc i W 'cAn -ICk[at ' ,
' of Ucensed Plumbertor Gas Fitter
umber.. � . Signature
Title ' , Gasfi ter + ' (
.
Master ' License Number ' 7794 .
CitytTown _ Journeyman
APPR4J'cb tOFFICE USE ONLY) • .