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HomeMy WebLinkAboutBLDG-22-003895 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rr " CITY YARMOUTH MA DATE (January 12,2022_I PERMIT# BLDG-22-003895 I: JOBSITE ADDRESS 9 KATHARYN MICHAEL RD OWNER'S NAME EVANS MARY I G OWNER ADDRESS 9 KATHARYN MICHAEL RD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ 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 I SPACE HEATER ROOF TOP UNIT TEST 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY El 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 he 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 it 4592 SIGNATURE MP❑MGF©JP❑ JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME: RCA Electric&Generators ADDRESS. 9 Hunters Trail, CITY Sandwich STATE MA ZIP 025632701 TEL 5084280449 FAX CELL EMAIL S3±ON MIA NVId #iftNa d $ :33d ❑ ❑ JJV Rd 3H1 SV S3A2j3S NOI1VOIlddV SIH1 oN SBA S310N NOI103dSNI 1VNIJ AlNO 3Sn NO.1.03dSNI 210A 3OVd SIHl S31ON NO1103dSNI SYJ HOfOa