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HomeMy WebLinkAboutBLDG-19-002868 ___ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _'°F,IQ in f CITY Yarmouth ! MA DATE 11/5/18 PERMIT#/92 -r? as62' JOBSITE ADDRESS 198 White Rock Rd__=.- - -'OWNER'S NAME Joseph Zaleski J1 3 GOWNER ADDRESS 198 White Rock Rd __ —� TEL914-319-9340 1FAX[_ TYPE OR OCCUPANCY TYPE COMMERCIALFi EDUCATIONAL 0 RESIDENTIAL EA PRINT CLEARLY NEW:L J RENOVATION:[ REPLACEMENT:Li PLANS SUBMITTED: YES Li NOE APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER it COOK STOVE 1 .. l DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE I 1 GENERATOR 1 GRILLE INFRARED HEATER I LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT 4 II 1 = , i, TEST ____ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER f INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [j]NO [3 IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ®+ OTHER TYPE INDEMNITY [j BOND [1 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 applic ion a true and accurate to best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will e in mp nc al rti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME William B.Holmes . LICENSE 44592- j S N URE MP MGF 0 JP ID JGF 0 LPGI❑ CORPORATION WIS 043585106 PARTNERSHIP D4 LLC[3# —1 COMPANY NAME: RCA Electrical Contractors Inc. 4 1 ADDRESS 381 Old Falmouth Road,Unit 13f ��� 4 7 L_2 .__�...-._e. [508.428-0449 CITY Marstons Mills STATE MA ZIP 02648 ITEC _ FAX CELL 'EMAIL ellen@rcaelectric .com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No �nj /� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ p114_ lS+ ' d l/ FEE: $ PERMIT# Cei / PLAN REVIEW NOTES �s/T ` / � 11g7��