HomeMy WebLinkAboutBLDG-19-001710 �. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'•IIVer7ar t CITY Yarmouth I MA DATE 9/17/18 PERMIT 1)f if-00 7/‘
JOBSITE ADDRESS!51 Traders Lane I OWNER'S NAME LBreck Sawyer y_.__.
OWNER ADDRESS [51 Traders Lane TEL 508-790-1363 1FAX1—
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL LI RESIDENTIAL(
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
M. —
BOOSTER
CONVERSION BURNER
COOK STOVE
FIREPLACE
FRYOLATOR
GENERATORFURNACE '
INFRAREDGRILLE _
LABORATORY COCKS 11111 lit
r MAKEUP AIR UNIT 111111111111111IMMINIM11111111111111111®111111111.11 1111111MMININ
OVEN / '
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER ____ — isms �' 11•111111111.111•11® ®N® 1111111 MI inn
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑+ 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 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this appli ti n e an ur o t best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application wi th ' nt vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME aN2liam B.Holmes I LICENSE#,4592-M,I SIGNATURE
–
MP El MGFEl JP JGF❑ LPGI❑ CORPORATION # 043585106 PARTNERSHIP L!#L ._ LLC❑#C--
COMPANY NAME: RCA Electrical Contractors Inc. 1 ADDRESS 381 Old Falmouth Road,Unit 13
CITY Marstons Mills - STATE MA ZIP 02648 TEL L8-428-0449 1
FAX CELL 1EMAIL ellen@rcaelectric.com
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
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�Q THIS APPLICATION SERVES AS THE PERMIT ❑ El ,c92ze O0A( FEE: $ PERMIT# .� 6f Y
` PLAN REVIEW NOTES GIS ///St