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HomeMy WebLinkAboutBLDG-22-000255 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I-III‘ CITY YARMOUTH MA DATE July 15,2021 PERMIT# BLDG-22-000255 JOBSITE ADDRESS 18 IVY LN OWNERS NAME WARREN FRANCES G OWNER ADDRESS 18 IVY LANE SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:0 REPLACEMENT:0 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 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 0 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© MGF ❑ JP 0 JGF❑ LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC ❑# COMPANY NAME: harwich port heating and cooling ADDRESS. 461 LOWER COUNTY ROAD, CITY Harwich Port STATE MA ZIP 02646 TEL 5084323959 FAX CELL EMAIL S310N M3IA321 NVld #111Na3d $:33d El 1IW213d 3H1 SV S3A113S NOIlV011ddV SIHl ON S8A S310N NO1103dSNI 1VNId AINO 3Sfl 80133dSNl 210d 30Vd SIHL S310N NO1103dSNl SVO HJl021