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HomeMy WebLinkAboutG-18-6817 (10A) Pot `77%266-?/?7 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Atilt" CITY Yarmouth , MA DATE 5/25/18 , PERMIT# IYDb9t Orr JOBSITE ADDRESS 5 Sycamore Way _ I OWNER'S NAME Helen Rotast t GOWNER ADDRESS 5 Sycamore Way — 3 TEL!508-694-6435 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Li PLANS SUBMITTED: YES El NO0 q APPLIANCES 7 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER I CONVERSION BURNER _ '. 1 COOK STOVE i , r d DIRECT VENT HEATER I I; _ DRYERI FIREPLACE - - . FRYOLATOR " i FURNACE GENERATOR 1 GRILLE i ) INFRARED HEATER ,_- LABORATORY COCKS - 1 MAKEUP AIR UNIT , OVEN ,. , ', POOL HEATER - ,! t __ - ROOM/SPACE HEATER I i • ROOF TOP UNIT TEST 1 — _ UNIT HEATER a l UNVENTED ROOM HEATER I WATER HEATER 1" 1 ii I-. t I THER- F P INSURAN E COVERAGE i. I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ' LIABILITY INSURANCE POLICY '2 OTHER TYPE INDEMNITY [j BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachuse S General L1Ars,,and/t t my signature on this permit application waives this requirement. CCrJ -V 6/. f ---, CHECK ONE ONLY: OWNER ® AGENT El SIGNATURE OF oirVIER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application ar we d accurat th t o y knowledge and that all plumbing work and installations performed under the permit issued for this application will be In a MI in o ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEWilliam B.Holmes 1 LICENSE# 4592-M _ S GNATURE MP 0 MGF DI JP 0 JGF© LPG![0 CORPORATION 0# 043585106 PARTNERSHIP Eiji, . 1 LLC 0# -` COMPANY NAME: RCA Electrical Contractors Inc. I ADDRESS 381 Old Fa __ - quad CITY Marstons Mills STATE MA ZIPI 02648 JTEL L508-428-0449 I FAX CELL !EMAIL'.billy@rcaelectric.com 1 424L ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES i IYes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 / 1�� ___ I FEE: $ PERMIT# -fes Gv/� D c! Gf39 /t / /// � PLAN REVIEW NOTES � �;• i�rff V//4/f �11/9-Q- 0q