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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
I Tilt=� CITY YARMOUTH MA DATE 08/23/19 PERMIT#�G,//C7 --0/0
JOBSITE ADDRESS 17 SEAGULL RD OWNER'S NAME CROWN CASTLE
GOWNER ADDRESS PMB 353-4017 WASHINGTON TEL 617-839-6907 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL at
PRINT
CLEARLY NEW: [1 RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 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
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER Run gas line from propane tank to generator for cell tQwer
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 ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massac efts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNA RE OF OWNS R AGENT
I hereby certify that all of the details and inf ation 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 corn nce with rtinent provision o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 1enZ . , Bousquet LICENSE# 3OS1. SIGNATU- '
MP❑ MGF 21 JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Consumers Propane ADDRESS 139 Hamlet Ave
CITY Woonsocket STATE RI ZIP 02895 TEL 401-762-5461
FAX 401-765-5360 CELL EMAIL
66 °O' , //
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
/ 4Lj_� �_ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
Zc /9 FEE: $ PERMIT#
•
PLAN REVIEW NOTES