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HomeMy WebLinkAboutG-19-1224 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE August 28,201i PERMIT it BLDG-19-001224 JOBSITE ADDRESS 64 RAINBOW RD OWNER'S NAME DASILVA MICHAEL J TR G OWNER ADDRESS 'THE DASILVA FAMILY IRR TRUST 39 BLENDALL ST BROCKTON MA TEL _ 02302 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL m PRINT CLEARLY NEW m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO© 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 Jiabilitv 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❑ 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. SIGNATURE OF OWNER OR AGENT I 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. PLUMBER-GASFITTER NAME Wiliam Holmes LICENSE# %4592 SIGNATURE MP© MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RCA ELETRICAL CONTRACTORS, IN ADDRESS 381 Old Falmouth Rd Unit 13, CITY Marstons Mills STATE MA ZIP[02648 _TEL 5084280449 FAX CELL EMAILIellen@rcaelectric.com I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECT4ON NATES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE:$ PERMIT# PLAN REVIEW NOTES i S . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ACC; Yarmouth06 r <CCITY MA DATE 8/21118 PERMIT#77D6 -�/p -,31a ,- JOBSITE ADDRESS'64 Rainbow Road , , , OWNER'S NAME Orlando DaSilva GOWNER ADDRESS 64 Rainbow Road ITEL( 508-771-5437 3FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL LI RESIDENTIAL El PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOL] APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER — BOOSTER ' I 1' 1E 1 CONVERSION BURNER COOK STOVE ' DIRECT VENT HEATER i, DRYER FIREPLACE FRYOLATOR ' - _ -_ ---- — __ _ _-. " — FURNACE i GENERATOR 1 1 GRILLE ! INFRARED HEATER ,' LABORATORY COCKS .- . ._ . ---- ---__ -- . . MAKEUP AIR UNIT OVEN POOL HEATER - ROOM/SPACE HEATER , ,.. ROOF TOP UNIT . u TEST 1 - . . __ . _ UNIT HEATER - - UNVENTED ROOM HEATER • WATER HEATER _.,,,_,._ - -- I OTHER --- - -- . .. . - -- ' • INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [A NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 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 I hereby certify that all of the details and information I have submitted or entered regarding this applicatio are true and accurate to the b st of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will n co pliance wi I P ' en rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAMEWilliam B.Holmes — I LICENSE#14592-M IG E MP❑ MGF Q+ JP❑ JGF Q LPG!ID CORPORATION❑+ # 043585106 PARTNERSHIP r1#j LLC C# COMPANY NAME: RCA Electrical Contractors Inc. ..,I ADDRESS 381 Old Falmouth Road,Unit 13 CITY I Marstons Mills STATE LMAJZIPL02648 _ ITEL 1508-428-0449 — FAX i�— CELL ;EMAIL ellen@rcaelectrlc.comI . . ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 /aria( /` //� `l} 'nom FEE: $ PERMIT# / tJ / f V ' / ' 0k PLAN REVIEW NOTES I C" ZIEI/-/ —.�tL 91/oh( /-AA