HomeMy WebLinkAboutBLDG-19-002428 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'_® CITY Yarmouth MA DATE 10/18/18 PERMIT#/ �7��,Tg(
JOBSITE ADDRESS 70 Captain York Road OWNER'S NAME Louise Wolf
GOWNER ADDRESS 70 Captain York Road TEL 715-308-1061 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL �
PRINT
CLEARLY NEW: ' RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES 1 FLOORS-0 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 1
FRYOLATOR
FURNACE
GENERATOR
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
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES j, ' 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 applic ion true an ur o t best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application wil •n omp nc a ti nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME William B. Holmes LICENSE# 4592-M SIGNATURE
MP MGF JP JGF LPGI CORPORATION # 043585106 PARTNERSHIP # LLC #
COMPANY NAME: RCA Electrical Contractors Inc. ADDRESS 381 Old Falmouth Road, Unit 13
CITY Marstons Mills STATE MA ZIP 02648 TEL 508-428-0449
FAX CELL EMAIL ellen@rcaelectric.com
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR LSE ONLY" FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
0" 0 4 / ,a FEE:$ PERMIT#
/(/ '7// Y
PLAN REVIEW NOTES
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