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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�';Wl s CITY Yarmouth �� I MA DATE X5/25/2018 PERMIT#134/2
JOBSITE ADDRESS 90 Fairwood Road 'OWNER'S NAME Eileen Palmer 1
GOWNER ADDRESS (90 Fairwood Road,S.Yarmouth 02664 _ , ]TEL1203-788-5764 JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL LEDUCATIONAL _ RESIDENTIAL E]
PRINT I 1
CLEARLY NEW:kJ RENOVATION:Li REPLACEMENT:[_] PLANS SUBMITTED: YES[L NOD]
APPLIANCES Z FLOORS-. BSM 1 2 34 5 6 7 8 9 10 11 12 13 14
BOILER — -- - — - -__-- ---- _ ---- —
BOOSTER - n , 1, li '
CONVERSION BURNER - 'l
COOK STOVE _
DIRECT VENT HEATER ' - -
DRYER '
FIREPLACE _ . .. . ._ ._. . . .. _ .. l_
FRYOLATOR
FURNACE _ _
GENERATOR 1 .
GRILLE -
INFRARED HEATER I -
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN POOL HEATER , , -
ROOM/SPACE HEATER ,
ROOF TOP UNIT
TEST - --- _.._ a .-._ . . . P .. _.
UNIT HEATER , t
UNVENTED ROOM HEATER R
WATER HEATER ___
_OTHER
i __ - - - - -- - - - - — - - -
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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 [ii NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
11.
LIABILITY INSURANCE POLICY C OTHER TYPE INDEMNITY [ j BOND [1,
't OWNER'S INS NCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachu s ener L ,2d that y signature on this permit application waives this requirement.
• .2%; M CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF O..
1PEER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application a tru and ccu�l�10 t es f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In p e i �/ert' ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME William B.Holmes _ j LICENSE#(4592-M j SIGNATURE
MP❑ MGF JP 0 JGF❑ LPGI❑ CORPORATION S]# 043585106 PARTNERSHIP Lit LLC C#I
COMPANY NAME:`RCA Electrical Contractors Inc. 1 ADDRESS 1381 Old Falmouth Road,Unit 13 _I
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CITY Marstons Mills 1 STATE!. MA ]ZIP I 02648 TEL 508-428-0449 -______j
FAX CELLJEMAIL billy@rcaelectric.com —
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yea No
THIS APPLICATION SEWER AS THE PERMIT 0 0
r,A rf FEE: $ PVEW NOTES
_ PLAN REVIEW NOTES
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