HomeMy WebLinkAboutBLDG-19-000616 -. . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�L, 10. a- _ p �"
'Al*' CITY 'YARMOUTH _ _ MA DATE 07/22/2018 PERMIT#,� /?—O�(pi&
JOBSITE ADDRESS 106 WIMBLEDON DR !OWNER'S NAME .BARCE
5oG OWNER ADDRESS ISAME TEL508-725 1955 FAX,
TYPE OR EDUCATIONAL RESIDENTIAL ,OCCUPANCY TYPE COMMERCIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:Ej PLANS SUBMITTED: YES Li N0
APPLIANCES 1 FLOORS—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i.-.I . ..._. .._,..� �
BOOSTER _.._r1 ,-,
CONVERSION BURNER s &_
COOK STOVE
DIRECT VENT HEATER -g F '11- —1 ,' , --------, ___"
r
DRYER t
FIREPLACE a
FRYOLATOR .._.
FURNACE
GENERATOR
GRILLE .: lr
INFRARED HEATER t_. S} gg t
LABORATORY COCKS ,. _
MAKEUP AIR UNIT r__.,-
OVEN t ':.
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER r
UNVENTED ROOM HEATER
WATER HEATER
" OTHER _ r g - f li ' ..._ _:.
F
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Lvj NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY , OTHER TYPE INDEMNITY BOND L
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 L„�-_
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. AO u
047(
PLUMBER-GASFITTER NAME Frank Roderick LICENSE# 7794 1SIGNATURE
MP MGF i JP Li JGF 0 LPGI Li CORPORATION i # 1762-C PARTNERSHIP # LLC t #
COMPANY NAME Rusty's Inc ADDRESS 222 Mid Tech Drive
CITY West Yarmouth STATE I MA ZIP 02673 TEL 508-775-1303
1 FAX 508-771-9310 CELL EMAILpneary�arustysmc.com _ _
J
Iti1O1ip