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HomeMy WebLinkAboutBLDG-23-003286 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �I CITY (YARMOUTH MA DATE 'December 13,2021 PERMIT# BLDG-23-003286 to JOBSITE ADDRESS 114 LILY POND DR OWNERS NAME 'Sue Ellen Ford G OWNER ADDRESS 14 LILY POND DR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 RESIDENTIAL PRINT PLANS SUBMITTED: YES 0 NO❑ CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT: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 0 OTHER OF INDEMNITY ID 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 LICENSE# 14592 I SIGNATURE MP❑ MGF © JP❑ JGF❑ LPG' 0 CORPORATION 0# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RCA ELECTRICAL CONTRACTORS ADDRESS. 19 Hunters Trail, CITY Sandwich STATE MA ZIP 1025632701 I TEL 15084280449 FAX 1 I CELL ' I EMAIL Iellen(a�rcaelectric.com 1 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "ki=•m CITY 'Yarmouth MA DATE 12/7/22 PERMIT# L3 - 3 Z ' JOBSITE ADDRESS 14 Lily Pond Drive OWNER'S NAME Sue Ellen Ford GOWNER ADDRESS same TEL 207-233-4107 FAX; TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL i PRINT CLEARLY NEW: + RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO`','. APPLIANCES 7 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER a BOOSTER CONVERSION BURNER COOK STOVE r r DIRECT VENT HEATER DRYER FIREPLACE ,m_FRYOLATOR FURNACE GENERATOR t 1 . GRILLE INFRARED HEATER ___ LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER - w ` 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 1' 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 [ 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 application re tr and acc to t be of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be i ianc it e nt vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME William B.Holmes LICENSE# 4592-M SIGN TU E MP MGF JP JGF, LPGI; CORPORATION ! #,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