HomeMy WebLinkAboutBLDG-23-005013 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
rAVAIRb CITY YARMOUTH MA DATE March 13,2023 PERMIT# BLDG-23-005013
JOBSITE ADDRESS 42 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 ❑
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO
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
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 1
OTHER DESCRIPTION:firepit
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO❑
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY El 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 Q MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME: harwich port heating and cooling ADDRESS. 461 lower county road,
CITY harwich port STATE MA ZIP 026460000 TEL 5084323959
FAX CELL EMAIL