HomeMy WebLinkAboutBLDP-17-004083 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_; CITY/TOWN Yarmouth MA DATE 02/08/17 PERMIT# ' P/7—(7041 P>
JOBSITEADDRESS 34 Berry Avenue_ OWNER'S NAME
P OWNER ADDRESS-West Yarmouth TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑x
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES El NO
FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 it
BATHTUB
CROSS CONNECTION DEVICE i
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01L/SAND SYSTEM •
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER .
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN -
INTERCEPTOR ONTER1OR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING -
OTHER f
INSURANCE COVERAGE
I have a current liability insurance policy or Its substantial equivalentwhich meets the requirements of MGL.Ch.142 YES 0/NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE 13oX BELOW
LIABILITY INSURANCE POLICY [ctr OTHER TYPE INDEMNITY ❑ BOND []
OWNER'S INSURANCE WAIVER:Jam 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 ~NY,
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 GWATll
MP g MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC Eil# 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 andy(a7hphcilc.com
IS /1—