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HomeMy WebLinkAboutBLDG-23-003750 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK C 4 iI' CITY YARMOUTH MA DATE January 10,2023 PERMIT# BLDG-23-003750 -17 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 III PRINT CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:El PLANS SUBMITTED: YES ❑ NO El FIXTURES 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 1 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 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 El 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# Massachusetts SIGNATURE MP El MGF ❑ JP El JGF El LPGI ❑ CORPORATION❑# PARTNERSHIP El# LLC El# COMPANY NAME: harwich port heating and cooling ADDRESS. 461 LOWER COUNTY ROAD, CITY Harwich Port STATE MA ZIP 026460000 TEL 5084323959 FAX CELL EMAIL