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HomeMy WebLinkAboutBLDG-23-01925 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK , rR CITY !YARMOUTH ;; I MA DATE (October 11,2022 PERMIT# BLDG 23-001925 JOBSITE ADDRESS 150 CARRIAGE LN OWNER'S NAME IMACHNIK CRAIG T G OWNER ADDRESS IMACHNIK TRACEY A 50 CARRIAGE LN YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL ID CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 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 ❑ 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 I LICENSE# 14592 I SIGNATURE MP❑ MGF © JP❑ JGF❑ LPGI ❑ CORPORATION❑#I I PARTNERSHIP ❑#I ILLC ❑#I COMPANY NAME: (RCA ELECTRICAL CONTRACTORS I ADDRESS. 19 Hunters Trail, CITY (Sandwich ISTATE IMA I ZIP 1025632701 I TEL 15084280449 FAX I I CELL I I EMAIL Iellen(a)rcaelectric.com I s SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK al-fed �.�� 1CITY "Yar ou V1 MA DATE 10/7/2022 PERMIT# 2_' 19 2 r .y,n 1 2O22 ... JOBSITE A DF ESS 50 Carriage Lane OWNER'S NAME Craig Machnik L BU UON GLJLMibi M6R=SS same TEL 508 360 7233 FAX 'TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: i RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO ,' APPLIANCES 7 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER , CONVERSION BURNER COOK STOVE sir DIRECT VENT HEATER m �. DRYER FIREPLACE FRYOLATOR . ,: FURNACE GENERATOR Mir GRILLE -I INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST 1 I UNIT HEATER UNVENTED ROOM HEATER 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 I' NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY ; BOND l 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 CHECK ONE ONLY: OWNER 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' com liance with all Pertinent ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME William B.Holmes LICENSE# 4592-M I 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 FAX CELL EMAIL ellen@rcaelectric.com