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HomeMy WebLinkAboutBLDG-19-001201 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ar t 1 CIT r, YARMOUTH MA DATE August 28, 2011 PERMIT# BLDG-19-001201 JOBSITE ADDRESS 73 CROWES PURCHASE OWNER'S NAME PATTON DELBERT E TRS G OWNER ADDRESS PATTON MARTHA 73 CROWES PURCHASE WEST YARMOUTH MA TEL 02673 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL m PRINT CLEARLY NEW m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NOLO 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 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT _ TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER _ OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability 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 0 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 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 LICENSE# SIGNATURE MPO MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# , PARTNERSHIP ❑# _LLC❑# COMPANY NAME: ADDRESS CITY STATE ZIP TEL FAX CELL EMAIL r- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTIQN NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ FEE:$ PERMIT# PLAN REVIEW NOTES r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1,='rte", C . 1 -z"ISL ,y CITY Yarmouth --I MA DATE 8/22118 PERMIT#cZG- /9- �,Gr O JOBSITE ADDRESS 73 Crowe's Purchase Road OWNER'S NAME Delbert Patton D GOWNER ADDRESS 73 CRowe's Purchase Road y 1 TEL1 508-775-8235FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL Li RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:LI REPLACEMENT:0 PLANS SUBMITTED: YESQ NO0 APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER a CONVERSION BURNER COOK STOVE + ✓ t DIRECT VENT HEATER DRYER - ._ _:: FIREPLACE FRYOLATOR i a i FURNACE — GENERATOR 1 GRILLE INFRARED HEATER c t. LABORATORY COCKS MAKEUP AIR UNIT a""_ ,. _;I _. ii , it l; �, I .... OVEN w _ .,a.. POOL HEATER1 ROOM ISPACE HEATER ROOF TOP UNIT _ _ TEST I i UNIT HEATER r , „ ; ,i 1 ,• 1 i . — —dl' UNVENTED ROOM HEATER � •� ` - �......q- i- — , + WATER HEATER OTHER I ; t INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO Q 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 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 Q AGENT Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applica n ar we nd at he est of my knowledge and that all plumbing work and installations performed under the permit issued for this application will ' c i all e provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME William B.Holmes LICENSE#`4592-M SIGNATURE I MP MGFQ+ JP JGFQ LPGIl-..J CORPORATION(+,J# 043585106 PARTNERSHIP 0#1 LLC D#r 1 COMPANY NAME: RCA Electrical Contractors Inc. 7 ADDRESS 381 Old Falmouth Road,Unit 13 CITY Marstons Mills STATE MA ZIP)02648 ITEL 508-428-0449 1 • FAX CELL 3EMAIL ellen@rcaelecric.com 51//62021) M71-S7ai? ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No / // THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ % Z a/ ill Cr t/E ,' 3 L (� FEE: $ PERMIT# / L //// li / / &/U PLAN REVIEW NOTES 117