HomeMy WebLinkAboutBLDG-19-001025 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
3_"41a CITY Yarmouth MA DATE 8/16/18 PERMIT#/ /)& /q'DOl0.CJ
JOBSITE ADDRESS 8 Ca.tain R der Road OWNER'S NAME Joanne Petty-McGinn
GOWNER ADDRESS 8 Captain Ryder Road — 1 TEL[508-335-1129 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW:❑+ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER l
CONVERSION BURNERn
COOK STOVE - 1
DIRECT VENT HEATER
DRYER
FIREPLACE .. --
FRYOLATOR
FURNACE - - ,- - - - - __ -- --i, -- I --- - - -
GENERATOR 1 ' •
GRILLE i ' I . .� 11 I
INFRARED HEATER '' I " 1
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN - I -
POOL HEATER `
ROOM I SPACE HEATER
ROOF TOP UNIT 1 • ,i •
TEST —1 - ,. . . . - _ ...
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER •
OTHER
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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 [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 [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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
._ CHECK ONE ONLY: OWNER ❑ AGENT Ci
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this app io :iiiv ac t a best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application II it e ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I William B.Holmes �j LICENSE# 4592-M SIGNATURE
MP 0 MGF❑+ JP❑ JGF❑ LPGI❑ CORPORATION[# 043585106 PARTNERSHIP❑#�-1 LLC❑#
COMPANY NAME:LRCA Electrical Contractors Inc. 'ADDRESS'381 Old Falmouth Road,Unit 13 i
CITY Marstons Mills j STATE MA ZIP[02648 TEL L598-428.0449 - 9
FAX CELL JEMAIL ellen@rcaelectnc.com
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
(� THIS APPLICATION SERVES AS THE PERMIT ❑ 0
V
4 /� &/5 �� FEE: $ PERMIT#
C/ PLAN REVIEW NOTES ("( -,(71
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