HomeMy WebLinkAboutBLDG-18-006516 S . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .1
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MA DATE[5115118PERMIT
JOBSITE ADDRESS'31 Iroquois Blvd __ 'OWNERS'OWNER'S NAME Gail GehlL
GOWNER ADDRESS31 Iroquois Blvd 17E4.802-376-9528 . 1FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[j EDUCATIONAL RESIDENTIAL El •
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CLEARLY NEW:D RENOVATION:❑ REPLACEMENT:Li PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER — a
BOOSTER ' I g 13 -
CONVERSION BURNER ,
COOK STOVE I .
DIRECT VENT HEATER .4'..
DRYER .' —
FIREPLACE
FRYOLATOR - -
FURNACE
GENERATOR 1
GRILLE A 4, . . '
INFRARED HEATER -
LABORATORY COCKS I '
MAKEUP AIR UNIT ,.
OVENi .i 4 4 I tI u i
POOL HEATER .)
ROOM ISPACE HEATER — }
ROOF TOP UNIT
TEST • 1 - --- — •
UNIT HEATER ,, s
UNVENTED ROOM HEATER I
•WATER HEATER ,I- " . _ i i._ . . ...
OTHER — — — , —
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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 Ej NO Q
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0+ OTHER TYPE INDEMNITY 0 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
' CHECK ONE ONLY: OWNER ❑ AGENT 0 V
SIGNATURE OF OWNER OR AGENT
1 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. H Q 1i—J _
PLUMBER-GASFITTER NAME William B.Holmes —1 LICENSE#14592-4 3 ~ SIGNATURE
MP❑ MGF a JP 0 JGF❑ LPG!C] CORPORATION L# PARTNERSHIP D# LLC[3#
COMPANY NAME: RCA Electrical Contractors Inc. ADDRESS 381 Old Falmouth Rd.Unit 13 1
CITY Marstons Mills : STATE MA ZIP 02648 TEL 508-428-0449
FAX !CELL , jEMAIL ellen@rcaelectric.com 1 -
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
" l ,/ Yes No
(/fin/[7�_ /j' THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ,j ��, �/�/ /n �/
A TAT it FEE: $ PERMIT# / �� 61,V„
\ PLAN REVIEW NOTES V ' r G,e