HomeMy WebLinkAboutBLDG-19-000149 /6'3. F
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY YARMOUTHPORT MA DATE 7/5/18 PERMIT#* t 'OW /' ?
JOBSITE ADDRESS 203 WILLOW STREET
Vn1'l ( .OWNER'S NAME BROWN LINDOUIST
OWNER ADDRESS 203 WILLOW STREET TEL 508-362 8382 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL A EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: __ REPLACEMENT: __. PLANS SUBMITTED: YES , NO
APPLIANCES 1 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 1
FRY OLATOR
FURNACE
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_®
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 OTHER TYPE 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.
CHECK ONE ONLY: OWNER AGENT
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 with all Pe ' nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ADAM TRAYNER LICENSE# 3880 SIGNATURE
MP MGF JP JGF LPGI CORPORATION � # 173 PARTNERSHIP # . LLC- #
COMPANY NAME: ROBIES HEATING&COOLING ;ADDRESS 279 YARMOUTH RD
CITY HYANNIS J STATE MA ZIP 02601 1TEL 508-775-3083
FAX 508-534-1272 CELL 508-775-3083 ;EMAIL MARY@ROBIES.COM
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No _
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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