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HomeMy WebLinkAboutBLDG-19-001225 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY'YARMOUTH I MA DATE'August 28,2011I PERMIT# BLDG-19-001225 JOBSITE ADDRESS 1887 GREAT ISLAND RD I OWNER'S NAME 'CHACE MALCOLM G III TR(EST OF) G OWNER ADDRESS MALCOLM G CHACE III TRUST 46 ABORN ST 4TH FLR PROVIDENCE RI TELI 02903 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 0 PRINT CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT.0 PLANS SUBMITTED:YES❑ NO0 FIXTURES FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER • _ CONVERSION BURNER COOK STOVE 1 _ 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 1 _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER • OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY BOND 0 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. SIGNATURE OF OWNER OR AGENT 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. PLUMBER-GASFITTER NAME Frank Roderick LICENSE#1762 SIGNATURE MP❑MGF❑JP❑ JGF❑ LPGI❑ CORPORATION©# 1762 PARTNERSHIP ❑#I ILLC❑# COMPANY NAME: Rustys Inc M 7794 ADDRESS 222 MID TECH DRIVE, CITY YARMOUTH STATE MA J ZIP 026732580 TEL FAX CELL EMAIL s • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION WA-ES Yes No THIS APPLICATION SERVES AS THE PERMIT❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �, w ' CITY Yarmouth g MA DATE 8/21/18 - PERMIT # /.-6 42;15 ,o JOBSITE ADDRESS 887 Great Island Road OWNER'S NAME Chase ,. GOWNER ADDRESS same TEL 508 775 0259 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ' ✓ ' PRINT CLEARLY NEW: RENOVATION: '' REPLACEMENT: PLANS SUBMITTED: YES NO i APPLIANCES -1 FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER j CONVERSION BURNER COOK STOVE 1 _ DIRECT VENT HEATER ., », DRYER FIREPLACE ,... FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS �.._ MAKEUP AIR UNIT __1 ;, . OVENI POOL HEATER g .W,... ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _ ---- --- ----- ----- - UNVENTED ROOM HEATER WATER HEATER_. OTHER 1 �: . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES i NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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. 7,,, zi,deiziez PLUMBER-GASFITTER NAME Frank Roderick LICENSE # 7794 SIGNATURE MP MGF JP JGF LPGI L �....(.? CORPORATION „� # 1762 C PARTNERSHIP # �,;,._ �..b _ LLC # _.»... COMPANY NAME: Rusty's Inc ' ADDRESS 222 Mid-Tech Drive m CITY West Yarmouth I STATE MA ZIP 02673 TEL 508-775-1303 FAX 508-771-9310 CELL EMAIL mburke@rustysinc.com 927944