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HomeMy WebLinkAboutBLDG-22-006539 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK h" L`i CITY IYARMOUTH I MA DATE IMay 13,2022 I PERMIT# BLDG-22-006539 JOBSITE ADDRESS 11070&1074 ROUTE 28 I OWNER'S NAME (DAVENPORT DEWITT TR I G OWNER ADDRESS 120 NORTH MAIN ST SOUTH YARMOUTH MA 02664 I TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL •I PRINT RESIDENTIAL ID CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO El FIXTURES 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 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER OTHER DESCRIPTION: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES © NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER OF 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. 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 landrew levesque I LICENSE# 13944 I MP❑ MGF ❑JP El JGF❑ LPGI El © CORPORATION # SIGNATURE 13944 I PARTNERSHIP ❑#I ILLC ❑#I I COMPANY NAME: IHARWICH PORT HEATING AND COOLING I ADDRESS. 1461 LOWER COUNTY ROAD, CITY (Harwich Port I STATE MA I I ZIP 102646 I TEL 5084323959 FAX I I CELL 1 I EMAIL