HomeMy WebLinkAboutBld-19-004776 L. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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— ITIL ,y CITY Yarmouth � �, MA DATE L2/12/19 PERMIT# 977
$50 JOBSITE ADDRESS 23 Oak Bluff OWNER'S NAME Mur h��
GOWNER ADDRESS same TEL FAX`
TYPE OR OCCUPANCY TYPE COMMERCIAL1 j EDUCATIONAL RESIDENTIAL �A
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CLEARLY NEW: ..,,., , RENOVATION:1 REPLACEMENT: PLANS SUBMITTED: YES J LLI
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER s _ u
BOOSTER ..,
CONVERSION BURNER ±w- _ 1, 1 ':
COOK STOVE 1 � .,
DIRECT VENT HEATER -, I t .
DRYER ` -- > J
FIREPLACE .. -u_ ...-_ .b .�_`. t . � ..t.� nt f s
FRYOLATOR `. . . ..;. _.. t €. E
_t FURNACE J , ��ti 11� t .�
GENERATOR '
GRILLE �- ; t I' 1: i�. . .�r � v�= - r.� t ��-
INFRARED HEATER l 1
37
LABORATORY COCKS € ._x- t ! ..'� L
MAKEUP AIR UNIT . .. J � f _ ?_,_. �__ • -,—
OVEN - v -�
POOL HEATER - t � ._
ROOM I SPACE HEATER �� _ t..` �� ��
ROOF TOP UNIT i ' -
TEST r a.i t'v. � .� . . --
UNIT HEATER l „ .__. t3 y
UNVENTED ROOM HEATER t Ifi t: —101: -: ,� r --
WATER HEATER ;
OTHER �_ l
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1 $ Iry -1
m„,_ —� _� .,,,___ „ INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES iii NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY !'.7,/,I OTHER TYPE INDEMNITY BOND [.,,_F
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 ',„,.,J AGENT 9
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 complianceh�Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Frank Roderick i LICENSE#p 7794 SIGNATURE
MP! MGF;_l JP; , JGF ,,_j LPGI!_;_j CORPORATION ;i #11762 C ;PARTNERSHIP # ., LLC j#
COMPANY NAME:I Rusty Inc. ADDRESS'222 Mid-Tech Drive
CITY I West Yarmouth
r STATE MA t ZIP 02673 TEL 508-7751303
FAX[508-771-9310 i CELL EMAIL;mburkeerussinc com ,
930101 -
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