HomeMy WebLinkAboutBLDG-16-005580 . " 1... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
5 =' h vz I CITY SOUTH YARMOUTH MA DATE 03/30/2016 PERMIT#ie/-4P-43 �
JOBSITE ADDRESS 44 GENEVA ROAD OWNER'S NAME CHERYL MATTESON g
G .OWNER ADDRESS 1 SAME TEL 508-398-3759 FAX ,.
N TYPE ORN. PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL Li RESIDENTIAL 0
CLEARLY NEW: RENOVATION:Li REPLACEMENT:EI PLANS SUBMITTED: YES 0 NO
V APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BOOSTER INN 1111111111ff Oil MN 1111.OMIMO FN AM OM f.._. I
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LABORATORY COCKS MN 111.11111111 ONOM O O OMB 11011.11111111
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POOL HEATER iiii ailli:NM N 111111 PSMI MN W all 11111111 MEW ,.. [ -
ROOM/SPACE HEATER Si.Om Naill linsomellirlinionan1.11111111111.111111.11.1
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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 0 NO L]
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ED 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 Lj AGENT Li
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.
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PLUMBER-GASFITTER NAME i Frank Roderick J LICENSE#-7-7-94 SIGNATURE LfJL
MP.L,1,„,1-- MGF ID JP 0 JGF 0 LPG ID CORPORATION Ej#a 1762-C 1 PARTNERSHIP LJ# i LLC r 1#
COMPANY NAME I Rus 's Inc. i ADDRESS 222 Mid-Tech Drive
CITY [West Yarmouth STATE MA ZIP 02673 ITEL 508-775-1303
FAX 508-771-9310 CELL EMAIL g
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