HomeMy WebLinkAboutBLDG-18-001580 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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mar..'y _• CITY ssW Yarmouth MA DATE 9/12/2017 PERMIT# /Y--"/7—�d/5 £
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f 9 JOBSITE ADDRESS 22 Rosemary Lane j OWNER'S NAME Lois Crocker
GOWNER ADDRESS Same TEL
TYPE OR ._ -._,�_ _..
PRINT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL RESIDENTIAL
CLEARLY NEW: w�.e° RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO
APPLIANCES 7 FLOORS-0 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
i FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST _
_JN'T HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTF,ER Cap Gas Line 1
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 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;ertify 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
anc that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
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PLUMBER-GASFITTER NAME Frank Roderick ' LICENSE# 7794
Massachusetts State PlumbingCode and Chapter 142 of the General Laws.
SIGNATURE
MP i MGF _, JP JGF LPGI CORPORATION # 1762-C PARTNERSHIP ro_ # LLC D#r
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 ssavery@rustysinc.com