HomeMy WebLinkAboutBLDG-19-002513 t ,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY South Yarmouth MA DATE 10/23/20158 PERMIT# /�—o6 /9-v
JOBSITE ADDRESS 109 River Street OWNER'S NAME McCarthy
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑x
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑X PLANS SUBMITTED: YES❑ NO El
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
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 aVNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 12. 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 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 GNATUSE
MP V[7 MGF EX JP❑ JGF❑ LPG!❑ 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 EMAIL andy(a�hphcinc.com
/1)4
._,
��
�.
V
���