HomeMy WebLinkAboutBLDG-17-006208 —T
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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,^^ ..°T.-„1 CITY :W Yarmouth MA DATE;5/23/17 1 PERMIT# a--d6/7�r/ f
30 JOBSITE ADDRESS 150 Crowell Rd 'OWNER'S NAME ,David Korn
GOWNER ADDRESS Same TELFAX �, .
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL', EDUCATIONAL j RESIDENTIAL LA
CLEARLY _NEW ,L1 RENOVATION:, REPLACEMENT:; i PLANS SUBMITTED: YESD NO:
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ____I i_ -r-1 _ _I J __J .
BOOSTER r°
CONVERSION BURNER _.T . .,I._._...JF.w.. _Li- 1:. j_..__-I_._.-i� I
_ 1
COOK STOVE '"
DIRECT VENT HEATER
DRYER .,..., .�'�_Ir; _ :__J .._.r , __,.___I-.-,.,,..._I,...:L1_1- — =1, .,. s .,. I ,...
FIREPLACE �I. J _ _I_.®�._i _.. , __,__J ' I. 1....:=--.. r I., I
FRYOLATOR I ®I � __�._r.,� m. i-. - J (�
FURNACE _i._.._....._I` j _I J_ ,-.�. I ,�I: , _. 1 _ . I
GENERATOR . .�.. .�_�I
GRILLE ._.,__I � I . - g '..��.�IE I, _. E ®I; I
INFRARED HEATER j
LABORATORY COCKS I- .. I J J , .
MAKEUP AIR UNIT _ _ �� " -_...:J''' -
OVEN
POOL HEATER . I___R_I 1.....__I J f 1_____f .I _I I I 1
ROOM/SPACE HEATER � _.-,....�1. I �.r.�m1 � _ rt
II__J_I am. _I m_ �. r. �_ ®
UNIT HEATER
UNVENTED ROOM HEATER ______1-_____J:__-_J_____ __I______I_____I_J_,,....,m...Il L� - .,,I
WATER HEATER_. -...____. .- ? I i 1_ 1 I, I I i I I I' IF I_
OTHER 1_LI l —•-.I-m_LH- _. _ . ,�... _JJ ,�_.._J_i_-__--.1'(( .7 ., m.�. .�.{jI JI �.I=1=1-
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J_ OTHER TYPE INDEMNITY BOND U
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 s, 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 6m!(
LICENSE#!7794 SIGNATURE
PLUMBER-GASFITTER NAME:Frank Roderick __e_x.
MP. MGF JP JGFrn_ L � �
PGI L CORPORATION # 1762 C PARTNERSHIP-2,1#:- LLC #
COMPANY NAME: Rust 's Inc. ADDRESS'222 Mid Tech Drive
West Yarmouth STATE MA -ZIP 02673 ,TEL 508508 3
CITY __ -
EMAIL=ssave • rust sinc.com
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FAX 508-771-9310 CELL_
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