HomeMy WebLinkAboutBLDG-19-001616 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
SWA__. t. CITY !YARMOUTHPORT ~yI MA DATE 9/4/18 I PERMIT# db-19-06/6/6
G JOBSITE ADDRESS' 2 WINDSWEPT PATH OWNER'S NAME !ZWICKER
OWNER ADDRESS i 2 WINDSWEPT PATH I TEL 978-502-2585 IFAX'
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL j RESIDENTIAL
PRINT
CLEARLY NEW:LI RENOVATION:J REPLACEMENT:❑ PLANS SUBMITTED: YES D NOEl
APPLIANCES 1 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
' n
BOOSTER
CONVERSION BURNERr " :
COOK STOVE —. — ____ ` _,T _1
DIRECT VENT HEATER T
DRYER i � ..� ___._ �
FIREPLACE
FRYOLATOR Tom. ^
— �
FURNACE
GENERATOR 1
GRILLE
I!!
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES a NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 'J 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
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 application are true and accurate t the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will ee n mpliance wi all P inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —/ , a
L�s— �` Y.1fr-pu t�
PLUMBER-GASFITTER NAME I ADAM TRAYNER LICENSE# 3880 1 SIGNATURE
MPJ MGF,J JP i JGF I LPG! CORPORATION # 173 ----1 PARTNERSHIP_I# ILLC at.
COMPANY NAME::ROBIES HEATING&COOLING 1 ADDRESS 279 YARMOUTH RD
CITY 'HYANNIS 1 STATE' MA IZIP;02601 — ]TEL:508-775-3083 I
FAX!508-534-1272 I CELL'508-775-3083 'EMAIL MARY@ROBIES.COM I
i
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yea No
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�J9 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 037 (
�j(� ( 1. 1���/� 2'/4 FEE: S PERMIT# / 1/7-
PLAN REVIEW NOTES /`/? 4