HomeMy WebLinkAboutG-19-823 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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I CITY Yarmouth MA DATE 8/8/18 PERMIT#,tD6•-JP-no i3
JOBSITE ADDRESS 845 Rte 28 OWNER'S NAME Yarmouth Food Pantry
GOWNER ADDRESS PO Box 982 West yarmouth,MA 02673 TEL 058-916-1617 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL[J RESIDENTIAL CI
PRINT
CLEARLY NEW:❑+ RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO❑+
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER 1111111MUSIK111111111111111111111111111111111111111111111 _, ,
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER 111111111111111M1111111111•111111111111111111111111111111111111111111111111111111KM01111
FIREPLACE11•111111111111111111111111111 -111111111111111111111111111111k111111
FRYOLATOR ���I��--���.�
FURNACE 11111111MISSIIIIIIIIIIIall11110111111111111111111111111111111111111111111110 ,
GENERATOR 1
GRILLE ®1111111a1111111.111111111111111111111111111111131Wallia
INFRARED HEATERa1111111
LABORATORY COCKS � � �
MAKEUP AIR UNIT � � I
OVEN 1111111111111111M111111111111111011111111111.111111111111111111111111MallISS
POOL HEATER 111111211111111111111111111.1111111111111111111111111110111111111111111111111111111111101.01111
ROOM I SPACE HEATER
ROOF TOP UNITrnn —anaa
TEST
UNIT HEATER 1111111111111111111111111111111111111111111111111111111111110111111111111111111Kallill
UNVENTED ROOM HEATER MallettlIMINWINMS11111111111111Miaar
WATER HEATER ___- —
OTHER — — 1—E-1111111111111111S11111•111111111111111111111.1111M1111111111111MINIX
11111111111W11111111.111a 11111111 a
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ 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
hereby certify that all of the details and Information I have submitted or entered regarding this a.. licati, are trueac• to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this applicatio b i p' r. wi I • inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4.
PLUMBER-GASFITTER NAME William B.Holmes LICENSE# 4592-M SIGNATURE
MP❑ MGF❑+ JP❑ JGF❑ LPG]❑ CORPORATION Q# 043585106 PARTNERSHIP❑# LLC❑#
COMPANY NAME: RCA Electrical Contractors Inc. ADDRESS 381 Old Falmouth Road,Unit 13
CITY Marstons Mills STATE MA ZIP 02648 ITEL 508-428-0449 . 1
FAX CELL EMAIL ellenmcrcaelectric.com
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 ` fe/h,e� it`�y
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FEE: $ PERMIT# v/v b/Co
PLAN REVIEW NOTES
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