HomeMy WebLinkAboutBLDP-17 VOID (2) � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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,'7 — CITY WYarmouth MA DATE, 11/18/16 PERMIT#' �
41.!-VO JOBSITE ADDRESS 7 Holmes Way OWNER'S NAME Angie Voumazos
GOWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL'S EDUCATIONAL j. RESIDENTIAL!,
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CLEARLY NEW: RENOVATION: REPLACEMENT: %J PLANS SUBMITTED: YES 7„,j NO
APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I_______1-._____1_____J_____I____I _._I_i_____J I I ___.,J` __J_.. _____J
BOOSTER _J„......_1. ...__..1 _ .I_. , ._1 I _____I __J _ I_ _____1 _.J'.___._I
CONVERSION BURNER a .„„ _____3__,.�_J, ' _ ��
COOK STOVE ,_.n.__ _.. `_ . _ tr __.r._.,_ __.m I- . _n 1 ,�. ,
DIRECT VENT HEATER .,,„_._.,J'__._JJ___I__.,... ____I___i__ _ J._., 1_I __I_L__I.__,e_I ._,1�__I
DRYER I _.._ _.I__I .,1 _.,- J`
FIREPLACE ._ .._. I I .1.2,:;_i
FRYOLATOR I-1_1_ ,._.., I` I I______J _ _12,._:.:,_.' -I .. ss._. ,,,I I-_--.-1. ___I I_J
FURNACE ...a. 1____J'___..._J_____1,__LIJ IJ_.._,..._... ... '�_._.J®_._J __._.J '11.1_1_1._j__ _ I_____I
GENERATOR I _,I_.,.__.J I.....,—.1 __I_I . I_,-.J--J 1_1
GRILLE _____J_Li_ _I: . _Li __.J; I_..w.1°____.. i:_I _ _ _j I I
INFRARED HEATER _J _J _. I__L. _,..J . — —5 _I
LABORATORY COCKS I___I______..I_._........_.._1___.,_.I__I_____L___I___I- .--J__I .1IL.__.1'— ____I
MAKEUP AIR UNIT ....._.j.J .-...,.,.._I.a____I ,____1 _,_,. a- --J2 .�__-I 1_1_1
OVEN °'I` _ _ ____.J I _ __II. -
POOL HEATER J I.._.Ir,---.J _I u..1 J. m1 m,.. 1. _-.I,_. '
ROOM/SPACE HEATERI ,�__I 3 _ _ � I__I__J
ROOF TOP UNIT __I...�_. I......._".......3, __. _.�._.. ._.I I_. i ,
TEST I. .,-J° ` - ,e.._J 1 I' .. .___l_ LLA _.___ i _.-
UNIT HEATER .,� J._- '®.,...�.1 .__ .J _..I 1 .__ `_.__-.1` w� _____-1-- J___I'�.__.�
UNVENTED ROOM HEATER
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WATER HEATER 1 1_.._-_H.____J _�_._1___J __L ___I.�__1,L__J._ - j_...._.i_. __I_ _I _____I
OTHER 1_,1_____I-_..,,_. I'= I _. ____I __. ____ I. ____I°__i I._�___I
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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 [A NO S
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .',1 OTHER TYPE INDEMNITY ,,,i BOND I,,1
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
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. A /►eUi
PLUMBER-GASFITTER NAME Frank Roderick 1 LICENSE# 7794 I SIGNATURE
MP J MGF JP ,‘„J JGF LPGI I CORPORATION !J#' 1762-C PARTNERSHIP_J# LLC _1#-, _
COMPANY NAME: Rusty's Inc. I ADDRESS 222 Mid Tech Drive
CITY West Yarmouth E STATE MA I ZIP 02673 _ TEL 1 508 775 1303
FAX 508-771-9310 I CELL EMAIL'nickrustysinc.com
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