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HomeMy WebLinkAboutBLDG-23-003646.: 11 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORKCl CITY YARMOUTH MA DATE January 05,2023 PERMIT# BLDG-23-003646 II JOBSITE ADDRESS 53 CHIPPING GREEN CIR OWNER'S NAME CULBRETH THOMAS D G OWNER ADDRESS CULBRETH HELENE 53 CHIPPING GREEN CIR SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL 12 PRINT CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO 0 FIXTURES FLOORS—• BSM 1 2 3 4 5 1 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 LICENSE# 4592 SIGNATURE MP❑ MGF © JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: RCA ELECTRICAL CONTRACTORS ADDRESS. 9 Hunters Trail, CITY Sandwich STATE MA ZIP 025632701 TEL 5084280449 FAX CELL EMAIL ellen(rD,rcaelectric.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK K �M.*ice'"l:f_ _ _CITY Yarmouth MA DATE 12/30/2022 PERMIT# Z 3 ("'1 JOBSITE ADDRESS'53 Chipping Green Circle OWNER'S NAME Helene Culbreth GOWNER ADDRESS same TEL 508-394-2549 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL : RESIDENTIAL PRINT CLEARLY NEW: + 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 ,- v ",,. '. BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE ter. „a �; INFRARED HEATER . LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER .1 ROOM/SPACE HEATER ��_ ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER e_ WATER HEATER t _. OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES F.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 F 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 a true and accurate to t best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will e in m al rtin t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME William B.Holmes LICENSE# 4592- S N URE MP MGF JP JGF LPGI CORPORATION + ,# 043585106 PARTNERSHIP! # LLC # COMPANY NAME:RCA Electrical Contractors Inc. ADDRESS 153 Commercial St. _. CITY Mash pee STATE MA ZIP 02649 TEL 508-428-0449 FAX CELL EMAIL ellen@rcaelectric.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES