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HomeMy WebLinkAboutBLDG-19-001557 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK tl 1=3t CITY Yarmouth --- � MA DATE 9/11/19 PERMIT#Ababa �'? i 5✓7 JOBSITE ADDRESS 70 Captain York Rd _ OWNER'S NAME Louise Wolf GOWNER ADDRESS 70 Captain York Rd.S.Yarmouth ______ TEL 715-308-1061 — }FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL[] RESIDENTIAL 9 PRINT CLEARLY NEW:Q+ RENOVATION:Li REPLACEMENT:0 PLANS SUBMITTED: YES[] NO +Q APPLIANCES 1 FLOORS- 13511 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER --- — 'Th- — — - — ,- BOOSTER I r CONVERSION BURNER - a _ COOK STOVE DIRECT VENT HEATER DRYER , FIREPLACE r FRYOLATOR FURNACE GENERATOR 1 , I - ' GRILLE INFRARED HEATER LABORATORY COCKS — MAKEUP AIR UNIT 1 OVEN ii POOL HEATER ROOM/SPACE HEATER '— ROOF TOP UNIT 1 ' ! TEST t - _ . . _ -__ . _ . ___ . UNIT HEATER UNVENTED ROOM HEATER WATER HEATER ' OTHER — INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO Q I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Li 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 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application a tru nd accurate to the best f my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in pr nce fyth rti pr ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.-- ®vI PLUMBER-GASFITTER NAME William B.Holmes LICENSE#14592-M NA R MP Q MGF Q+ JP 0 JGF® LPGI Li- CORPORATION I,±j# 043585106 PARTNERSHIP(,,,,;# 1 LLC D# COMPANY NAME: RCA Electrical Contractors Inc. ADDRESS 1381 Old Falmouth Road,Unit 13 _ Y__1 CITY Marstons Mills 1 STATE MA 'ZIP 102648 jTEL 508-428-0449 FAX „CELL ;EMAIL ellenearcaelectdc.com 1 L2 U}' t r ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 1 L C)6'V / 4 ✓ FEE: $ PERMIT# PLAN REVIEW NOTES Oil( 461/4