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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I YARMOUTHPORT I MA DATE 19/4/18 I PERMIT# h lr l7`Q0l6/7
JOBSITE ADDRESSI 42 HOMESTEAD LANE I OWNER'S NAME COHEN
GOWNER ADDRESS 42 HOMESTEAD LANE I TEL 508-362-1905 /FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:El REPLACEMENT:Li PLANS SUBMITTED: YES=J NO ii
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i _' i
BOOSTER h�. T _ — ' -Te'• Ps
CONVERSION BURNER �'— —"
COOK STOVE —_' _
DIRECT VENT HEATER — T' —
DRYER
FIREPLACE —+ — — — — --
FRYOLATOR "
FURNACE
GENERATOR t
GRILLE � ' _ -
INFRARED HEATER '
LABORATORY COCKS I ' - _ - �, __ —
MAKEUP AIR UNIT
OVEN
POOL HEATER — —
ROOM/SPACE HEATER I— _
ROOF TOP UNIT "
TEST — r.
.—
�—
UNIT HEATER I
—
UNVENTED ROOM HEATER — — '-�
WATER HEATER
—
OTHER .. .-_ -- � ...�. '____ -- -_._ —. �-<
—. — —
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D NO J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY F, J OTHER TYPE INDEMNITY j BOND ❑
OWNER'S INSURANCE WAIVER:lam 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 El AGENT lEl
SIGNATURE OF OWNER OR AGENT
1 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 • in compliance with I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Ir
PLUMBER-GASFITTER NAME;ADAM TRAYNER 1 LICENSE#1-3 0 J 'SIGNATURE
MP'_J MGF JP : JGF LPGI CORPORATION J#' 173 IPARTNERSHIPEl# '1 LLC_J#.
COMPANY NAME: ROBIES HEATING&COOLING ADDRESS' 279 YARMOUTH RD
CITY HYANNIS — i STATE MA I ZIP,02601 ,TEL' 508-775-3083 —
FAX 508-534-1272 I CELL.508-775-3083 'EMAIL'MARY@ROBIES.COM
•
ROUGH CAS INSPECTION NOTES THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
J� /C//L�� THIS APPLICATION SERVES AS THE PERMIT El El
NO I/ 6 / T5 FEE: $ PERMIT# F`CLh'i v `-/ LE
PLAN REVIEW NOTES
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