HomeMy WebLinkAboutBLDG-21-001152 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTH MA DATE September 03,202 PERMIT# BLDG-21-001152
JOBSITE ADDRESS 47 SISTERS CIR OWNER'S NAME ROBERTSON DOUGLAS A TRS
G OWNER ADDRESS RYER JANE E TRS 868 WATERTOWN ST W NEWTON MA 02465 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO ❑
FIXTURES FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER -
FIREPLACE 1
FRYOLATOR _
FURNACE 1
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
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 ❑
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 ANDREW LEVESQUE LICENSE# 15162 SIGNATURE
MP El MGF ❑ JP❑ JGF❑ LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: HARWICHPORT HEATING AND COOLING ADDRESS. 461 LOWER COUNTY ROAD,
CITY HARWICHPORT STATE MA ZIP 02646 TEL
FAX CELL EMAIL andy(ahphcllc.com
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
YARMOUTH PORT
CITY MA DATE 8/27/20 PERMIT#11W"24'OD)ICv
JOBSITEADDRESS 47 SISTER CIRCLE OWNER'S NAME BASSII
GOWNER ADDRESS TEL 774-487-0807 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW:® RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES.' FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE 1
DIRECT VENT HEATER
DRYER
FIREPLACE 1
FRYOLATOR
FURNACE 1
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I 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 l ' 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 ❑ AGENT 0
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 GNATUSZ
MP VCj MGF[X JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC Ezr# 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 andylu'�,hphcinc.com
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