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HomeMy WebLinkAboutG-19-245 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _:Llan=_;_'' �/ c.Wt(-cf CITY Yarmouth — --� MA DATE 7/6/18 PERMIT#B T%`� 9Od 4YS JOBSITE ADDRESS 86 Lookout Road OWNER'S NAME Jerry Wilson GOWNER ADDRESS 86 Lookout Road TEL(614-537-8757 FAX j TYPE OR OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL[❑ RESIDENTIAL Ej PRINT CLEARLY I NEW:❑+ RENOVATION:LI REPLACEMENT:0 PLANS SUBMITTED: YES ED NOQ APPLIANCES-1 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 f a I � I `r s 1 'I 1 DRYER FIREPLACE _ - _ - - - - - -- FRYOLATOR I + I .I . t FURNACE GENERATOR 1 - --... --I --._._ __...- I -.... -._-1 GRILLE I INFRARED HEATER ? I , I i LABORATORYCOCKS :. MAKEUP AIR UNIT OVEN 1 y 1 POOL HEATER ROOM ISPACE HEATER i ? I i ROOF TOP UNIT ,, _..___, t TEST 1 I I UNIT HEATER UNVENTED ROOM HEATER `m _. I : 7 ' — WATER HEATER OTHER 1 41_._ 1 — I a 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ©+ 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 intonation I have submitted or entered regarding this applicat n ar e d at he est of my knowledge and that all plumbing work and installations pertained under the permit issued for this application will ' c i all r 'sin of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME William B.Holmes - I LICENSE#i 4592-M 1 SIGNATURE MP❑ MGF❑+ JP❑ JGF❑ LPG'U CORPORATION El# 043585106 !PARTNERSHIP D# j LLC❑#— COMPANY NAME: RCA Electrical Contractors Inc. ADDRESS 381 Old Falmouth Road,Unit 13 CITY Marstons Mills j STATE MA ZIPI 02648 ]TEL 508428.0449 FAX CELL ]EMAIL ellen@rcaelectric.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 N r dif CS • ' /86,662/ „...„, FEE: $ PERMIT# _ D ' PLAN REVIEW NOTES a�