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HomeMy WebLinkAboutBLDG-18-007025 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kr/ CITY IARMOUTH MA DATE June 12,2018 PERMIT# BLDG-18-007025 JOBSITE ADDRESS 72 BROOKHILL LN OWNER'S NAME APPLETON DANIEL F JR CO-TRS G OWNER ADDRESS APPLETON MARY T CO-TRS 72 BROOKHILL LN WEST YARMOUTH TEL MA 02664 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT CLEARLY NEW © RENOVATION:❑ REPLACEMENT:❑ 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 DIRECT VENT HEATER _ DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR 1 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 © NOD IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF INDEMNITY El 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. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are hue 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 William Holmes LICENSE# 3942 SIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: WILLIAM B HOLMES ADDRESS 9 HUNTERS TRL, CITY SANDWICH STATE MA ZIP 025632701 TEL FAX _ CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No _ THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE:$ PERMIT# PLAN REVIEW NOTES P-111C—a7-4. 4 (.-14/5 27 (90/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK °vine=,' __ nn ; '"I� t, CITY [Yarmouth 1 MA DATE 6/612018 J PERMIT# /,,��''- �t r/ft-Cd2Zf AMITEADDRESS 72 Brookhill Lane OWNER'S NAME [Joe Brouillard Is OWNER ADDRESS 72 Brookhill Lane,W.Yarmouth 02673 TE 508-018-8877 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[.1 EDUCATIONAL fl RESIDENTIAL 0+ PRINT CLEARLY NEW:[ I RENOVATION:U REPLACEMENT:[,_.] PLANS SUBMITTED: YES0 NO0+ APPLIANCES 1 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER --_ __.. . _ _ _ .. . .__ _ —_ BOOSTER CONVERSION BURNER • • COOK STOVE A DIRECT VENT HEATER i E DRYERF ' �i FIREPLACE , I FRYOLATOR ' FURNACEI I GENERATOR 1 . GRILLE 7 ' - INFRARED HEATERI t , LABORATORY COCKS ' MAKEUP AIR UNIT -- OVEN , - POOL HEATER _ , ROOM/SPACE HEATER ' ROOF TOP UNIT 1I I - I TEST , . _ . - . _ , . - . UNIT HEATER \ ' UNVENTED ROOM HEATER WATER HEATER .i OTHERi . t INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I+I NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0] 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 e true and accurate to the bes of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in ompl nce with erti t pr ision of the Massachusetts State' mbing Code and Chapter 142 of the General Laws. PLUMBER-GAS7ITTER NAME William B.HolmesLICENSE#14592-M 1 NA MP MGF 0 JP JGF 0 LPGI(1 CORPORATION[+#{043585106)PARTNERSHIP[.]# LLCE#F COMPANY NAME: RCA Electrical Contractors Inc. ADDRESS 381 Old Falmouth Road,Unit 13 CITY I Marstons Mills _I STATE LMA J ZIP 02648 )TEL L508-428-0449 1 FAX (CELL ; billl EMAIL y@rcaeectric.com —_ ROUGH CAS INSPECTION NOTES THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No �7 ��/./ ', ) THIS APPLICATION SERVES AS THE PERMIT 0 0 /9 • L©k FEE: $ PERMIT i / 2-6FLANREVIEW NOTES be Cana i • J