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HomeMy WebLinkAboutBldp-20-001448 Y nn MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _t;tOet CITYIToWN Yarmouthport MA DATE 9/11/2019 PERMIT it gi•-1✓P'f —(10 OW JOBSITEADDRESS 69 Kates Path Unit C OWNER'S NAME Dunham P , OWNER ADDRESS 69 Kates Path Unit C TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:E PLANS SUBMITTED:YES❑ NO❑ FIXTURES I- FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - • CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN - INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN • SHOWER STALL SERVICE/MOP SINK TOILET • URINAL WASHING MACHINE CONNECTION • WATER HEATER ALL TYPES 1 WATER PIPING - - OTHER 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 K' 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 sighahire oh 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 to the best of my know[edge 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-GASFITTERNAME Andrew Levesque LICENSE# pL15162 GNAT1) • MP L( MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC f# 3944 • COMPANY NAME Harwich Port Heating&Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich-Port STATE MA zip 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andy cnhphcllc.com • • • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 6'1Vim.7 Yarmouth port MA DATE 9/11/2019 PERMIT ,44 l q u CITY p /� JOBSITE ADDRESS 69 Kates Path Unit C OWNER'S NAME Dunham GOWNER ADDRESS same TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-0 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 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0/NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY U. OTHER TYPE INDEMNITY 0 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 0 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 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 Andrew Levesque LICENSE# PL15162 GNATU MP Ex MGF M' JP❑ JGF❑ LPG!❑ CORPORATION 0# PARTNERSHIP❑# LLC gi# 3944 COMPANY NAME Harwich Port Heating &Cooling LLC ADDRESS 461 Lower County Rd CITY Harwich Port STATE MA ZIP 02646 TEL 508-432-3959 FAX 508-432-6075 CELL 508-958-4874 EMAIL andyAhphcinc.com v