HomeMy WebLinkAboutBLDP&G-18-005037 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY W.YARMOUTH MA DATE 03/09/2018 PERMIT# /3(/)P-17-4165°61
`y�o JOBSITE ADDRESS 12 LEONARD AVE .. OWNER'S NAME MARIE FLETCHER
OWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL i,, 1 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM '
DEDICATED GRAY WATER SYSTEM ,•
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
,.. 4 . ;, ...
DRINKING FOUNTAIN )
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
WATER PIPING
OTHER BACK FLOW
•
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES' i NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY,.,di] OTHER TYPE OF 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / N y w /J_1-141-11C
PLUMBER'S NAME Frank W.Roderick i LICENSE# 7794 SIGNATURE
MP,i JP ,, j CORPORATION #i 1762-C PARTNERSHIP # LLC #
COMPANY NAME Rustys Inc. ,ADDRESS 222 Mid Tech Drive
CITY West Yarmouth -J STATE: MA ZIP 02673 I TEL'508 775 1303
_
FAX 5, ...__
08-771-9310 CELL 3 EMAIL
-��- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
®''p1 CITY W.YARMOUTH MA DATE 03/09/2018 PERMIT#II/41)-/r-c( 667
1 40' JOBSITE ADDRESS 12 LEONARD AVE OWNER'S NAME MARIE FLETCHER
GOWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO ,�
APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY / 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 compliance
with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /ZOGutNt/
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 SIGNATURE
MP MGF JP JGF LPGI CORPORATION # 1762-C PARTNERSHIP # LLC #
COMPANY NAME: Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 CELL EMAIL