HomeMy WebLinkAboutG-14-881 �� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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_ 4I1 J CITY SOUTH YARMOUTH I MA DATE 03/28/2014 PERMIT# big in
lia• JOBSITE ADDRESS 16 Highland ave I OWNER'S NAME George Parsons
G % OWNER ADDRESS 23 Brewster Road Arlington,MA 02174 I TEL 508-394-8396 FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Li
\ CLEARLY. NEW:EI RENOVATION:LI REPLACEMENT:CI PLANS SUBMITTED: YES NO[]
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 BOILER ,_J _J____)i____J J I _.
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\� BOOSTER I rRz-I I I.:7-4)-;;;;-i -rr;-1 _-Lit- 1IBJ -9z I ,. .J-, ,
CONVERSION BURNER lam l vx- 1' „zlir,JAw.,1 .r m.)J it r^w"1 1 - ..,r._.Z-J', ' -"" '"'r I,_,,,,
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' COOK STOVE 11 _1‘._1____11_._....I' ---J ..-.1' I'--J ILD
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DIRECT VENT HEATER ham' ...JI I-.�,J = I�' '-J . __J . J I J... J
DRYER (ane-r,j l®.-rrr' _ '• Imir-,r11.,-a„J . R,,-•-r1 in-m-1I-Vrr-d -cr•-,r,_1I .I1
FIREPLACE f
FRYOLATOR 4x-�-4'i� ^�--aa^�r�i .,.. _i -.- _ __ � -."'�J w�r-2v.J-c-tt��rxr^rr' �x-•r I ^s-^a
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FURNACE CRE"!""' ' 1 I _._.. _.-J -rnarJ
GENERATOR _._.._,.1'x._..1' I ,,.,,.,_,1.r..._l ,---J .._..J-1 tJ I�,.s_,1 ,
GRILLE 1�__1'. .J1 I_..--J�. . ___J'_.J _ 1........1 -..._JL.._._,
INFRARED HEATER l ___ -- 1
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LABORATORY COCKS
MAKEUP AIR UNIT I _.. „eI i _�..J
OVEN 1—r1 ...R.,4- -E„It-.....4 -,--J 1 ,-„1 ,.. 1'_. 1' .-._
POOL HEATER J !
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ROOF TOP UNIT
ROOM I SPACE HEATER
TEST ,...I „
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Id lalltilliallial.11311.011.01110111.$1111111.111101111011.1111
OSLO 1 BUILDING id, , RTMENT 1 ,
- ---- — -- -- -- INSURANCE COVERAGE
I have a current liability Insurance 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 D OTHER TYPE 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 comp with Pe IJ oof the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.. -
PLUMBER-GASFITTER NAME Frank Roderick I LICENSE# 7794 ' ° . SIGNATURE -
i MP[l MGF ID •
❑ JGF❑ LPGI❑ CORPORATION 0+, # 1762-C PARTNERSHIP❑# LLC❑#�� ——
COMPANY NAME: Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth I STATE MA ZIP 02673 ITEL 508-775-1303 I
FAX 508-771-9310 I CELL EMAIL I