HomeMy WebLinkAboutBLDP&G-18-004106 1,
. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
m di -o°� � CITY t,(j t' piYYLp[ V1 MA DATE PERMIT# d P ��e&
JOBSITE ADDRESS 3 al'0th4 ( 673y4 V...4 OWNER'S NAME )cient? ive , ' j cent I
POWNER ADDRESS Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL fl RESIDENTIAL[B
PRINT
CLEARLY NEW: RENOVATION:U REPLACEMENT:D PLANS SUBMITTED: YES Q NO
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i f,--<, 1r----. d 9 ,i ,
CROSS CONNECTION DEVICE
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DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM ;, . (1„ 11
DEDICATED GREASE SYSTEM 11
DEDICATED GRAY WATER SYSTEM 11"--1I (7--
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER I i c •
DRINKING FOUNTAIN _n _a �., I 1t it a..�
FOOD DISPOSER ! ( ) II "F ?
FLOOR/AREA DRAIN , 3 �. 1 _ . _,..,
INTERCEPTOR(INTERIOR) ' __11- u I® — 1 _ :�.° C. .—i - i_ --)-.-. . ._. .
KITCHEN SINK 1 n 1 [ F 1_ .� 1
LAVATORY Ca 1� 1#�
ROOF DRAIN ��`1
3 1
SHOWER STALL 1 . , ..-.1 l
SERVICE/MOP SINK 1 . 11 ri1-11€ .(i
TOILET ®.... ,
URINAL e k1--- n l �_..... • -;
WASHING MACHINE CONNECTION 1 �
WATER HEATER ALL TYPES I .. ` ii -
WATER PIPING
1 �.
OTHER 'BACK FLOW
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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 i NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE OF INDEMNITY BOND E
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 0 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 toe best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp!'- vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r —
PLUMBER'S NAME Frank W.Roderick LICENSE# 7794 SIGNA i urcc
MP_ij JP0 CORPORATION LI# 1762-C PARTNERSHIP Q#' ILLCEJ#
COMPANY NAME Rusty's Inc. I ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA ZIP 02673 TEL 508-775-1303
FAX 508-771-9310 1 CELL EMAIL ssavery@rustysinc.com
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
mIlUarr- CITYj MA DATE l;' J�.-ti PERMIT#IBC/�l'�-J�"'� ' �jL% .
Lip JOBSITE ADDRESS � l Cyr ...( K(1 OWNER'S NAMETD6yien IC_._-2�►-I
GOWNER ADDRESS Same TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL ,J RESIDENTIAL V
CLEARLY NEW: RENOVATION: REPLACEMENT: .7 PLANS SUBMITTED: YES!_r NO
APPLIANCES-1 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 I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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 d 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 compli nce with all Pe ine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. „/,
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 /(� SIGNATURE
MP ..ate MGF ED JP -1 JGF LPGI CORPORATION � # 1762-C PARTNERSHIP # LLC #
COMPANY NAME: Rusty's Inc. ADDRESS 222 Mid-Tech Drive
CITY West Yarmouth STATE MA E ZIP 02673 TEL 508-775 1303
FAX 508-771-9310 CELL EMAIL ssavery@rustysinc.com
L/C /--