HomeMy WebLinkAboutBLDG-23-002959 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'` CITY YARMOUTH MA DATE November 29,202; PERMIT# BLDG-23-002959
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JOBSITE ADDRESS 71 SMITHS POINT RD MAbv 1#wae. OWNER'S NAME 'NOLEN CHRISTIAN
G OWNER ADDRESS 57 RUSSELL AVE WATERTOWN MA 02472 TEL'
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO❑
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 1
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1
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 ❑ NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF 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.
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 (William Holmes LICENSE# 14592 SIGNATURE
MP 0 MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION❑#I ( PARTNERSHIP ❑# LLC ❑# I
COMPANY NAME: (RCA ELECTRICAL CONTRACTORS ADDRESS. 19 Hunters Trail, I
CITY (Sandwich (STATE MA ZIP 1025632701 I TEL 15084280449
FAX 1 'CELL 1 1 EMAIL Iellen(atrcaelectric.com 1
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
L.'' st_i=1 CITY 'Yarmouth MA DATE 11/21/2022 PERMIT# 23 2 9 S 9
JOBSITE ADDRESS 71 Smiths Point Rd-main house OWNER'SD NAME 'Christian&Susan Nolen Denny
OWNER ADDRESS 71 Appleton St Cambrid e, MA 02138 TEL 857 212 9664 FAX
pl? 9
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 3
PRINT RESIDENTIAL a -_
CLEARLY NEW  RENOVATION: REPLACEMENT:;. PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILERI
BOOSTER
CONVERSION BURNER
COOK STOVE
DRYER ,
FIREPLACE ,
GENERATOR i
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER _. .
ROOF TOP UNIT 6
TEST
UNIT HEATER
UNVENTED ROOM HEATER
a . .= e e, e., ,, 6.
e
WATER HEATER
OTHER
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 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 applicati, are'ue and acc ate to he ,"'.st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will 1:). in co plia e J II P e .rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' ;
aft
PLUMBER-GASFITTER NAME William B.Holmes LICENSE#z 4592-M SIG IATu RE
MP MGF ' - JP JGF LPGI CORPORATION i # 043585106 ;PARTNERSHIP „# LLC #
COMPANY NAME:RCA Electrical Contractors Inc. ADDRESS' 153 Commercial St.
CITY Mashpee STATE" MA ZIP 02649 TEL 508-428-0449
CELL EMAIL ellen@rcaelectric.com
FAX a electric.com - >