HomeMy WebLinkAboutP-14-639 •C. Zls MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1 `;=11III-yq CITY SOUTH YARMOUTH I MA DATE 03/28/2014 PERMIT# ftu% — 65?
l JOBSITE ADDRESS 16 Highland Ave I OWNER'S NAME George Parsons
P ,' OWNER ADDRESS 23 Brewster Road Arlington,MA 02174 I TEL 508-394-8396 FAX
‘1\ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q
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N CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q PLANS SUBMITTED: YES❑ NOD
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BUILDING D- ENT INSURANCE COVERAGE:
I axe a current I II surance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES D NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑+ OTHER TYPE OF 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 will be In co pllance with all e t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 7794 IGNATURE
MPD JP 1:1 CORPORATIOND# 1762-C PARTNERSHIP I:1# LLC I:1#
COMPANY NAME Rusty's Inc. ADDRESS 222 Mid-Tech Drive
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' CITY West Yarmouth STATE MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL