HomeMy WebLinkAboutBLDG-19-001465 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-",khyc CITY Yarmouth MA DATE 9/7/18 PERMIT# /_/ ' -oil,
JOBSITE ADDRESS 47 Trowbrid.e Path J OWNER'S NAME William Keener
GOWNER ADDRESS L47 Trowbridge Path West Yarmouth — - I TEL"508-398-5651 FAX
TYPPIENOR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL L] RESIDENTIAL❑
PR
CLEARLY NEW:❑+ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 1 FLOORS–. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER U
CONVERSION BURNER
l b I
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE _ ___
GENERATOR 1
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []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 Information I have submitted or entered regarding this applicatio are t e a ac t b t of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be r t ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME William B.Holmes _LICENSE#14592-M SIGNATURE
MP❑ MGF 0 JP❑ JGF❑ LPG!❑CORPORATION 0# 043585106 PARTNERSHIP EC LLC❑#
COMPANY NAME: RCA Electrical Contractors Inc. ADDRESS 381 Old Falmouth Road,Unit 13 1
CITY Marstons Mills STATE in ZIPL02648 jTEL 508-428-0449
FAX CELL IEMAIL ellen@rcaelectric.com 1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
�/J L jn /j� / THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /�/'� ( g
e I OAt FEE: $ PERMR# /✓-/AL1 / "%7/�
R., / /Obi/�i PLAN REVIEW NOTES II