HomeMy WebLinkAboutBldp-20-001484 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING
WORK
= '=a Yarmouth port 09/13/2019
CITY/TOWN P MA DATE PERMIT#A40i0 '
070-de Iy
•
JOBSITEADDRESS69 Kates Path Unit C OWNER'S NAME Dunham
p OWNER ADDRESS 69 Kates Path Unit C TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL.t C
PRINT
CLEARLY NEW:D RENOVATION:❑ REPLACEMENT;a PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—} 8SM 1 2 3 4 5 5 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
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 E ' OTHER TYPE INDEMNITY ❑ BOND ❑ 4
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 ONLYt OWNER ❑ AGENT.❑
SIGNATURE OF OWNER OR AGENT
l 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 GN TA U
MP M' MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC g# 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 _ atA1L andy(t:r7,hphcllc.com
•
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__� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
;r";= cln Yarmouthport MA DATE 09/13/2019 PERMIT# /40)0—/ 7 3y
JOBSITE ADDRESS 69 Kates Path Unit C OWNER'S NAME Dunham
GOWNER ADDRESS 69 Kates Path Unit C TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E lx
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:j PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS- _ 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 ["NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY G2i 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 ❑
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 LICENSE# -f "'"``i� GNATU ��
Andrew Levesque PL15162
MP Ez( MGF g JP❑ JGF❑ LPG!❑ CORPORATION❑# PARTNERSHIP❑# LLC 121# 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 andyhphcinc.com
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