HomeMy WebLinkAboutBLDG-18-003876 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK /�
s CITY WEST YARMOUTH MA DATE 1/3/2018 PERMIT#/3/!(-'/ra✓87C,
GJOBSITEADDRESS 300 BUCK ISLAND RD U�/tY 2.8 OWNER'S NAME LEBLANC
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY
NEW:0 RENOVATION:0 REPLACEMENT:❑, PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—. ESM 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 1
GENERATOR
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
INSURANCE COVERAGE r��
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES GYRO ❑
1 W YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ci - OTHER TYPE INDEMNITY ❑ BOND 0
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 0
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 Pediment provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LICENSE# pL15162PLUMBER-GASFrTER NAME Andrew Levesque
GNAru
MP MGF 12. JP 0 JGF 0 LPG!0 CORPORATION 0# PARTNERSHIP❑# LLC # 3944
COMPANY NAME -Harwich Port Heating &Cooling LLC ADDRESS 461 Lower County Rd
cm, Harwich Port STATE MA Zip 02646 TEL 508-432-3959
FAX 508-432-6075 CELL 508-958-4874 EMAIL andyAhphcinc.com
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