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HomeMy WebLinkAboutBLDP&G-18-001891 t .1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r=1 w= ' CITYlrowN South Yarmouth MA DATE 9/25/2017 PERMIT# 3-10--Qd4'Q/ ' JOBSITEADDRESS 43 Cove View Drive OWNER'S NAME Sellers P ' OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL E PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:lI PLANS SUBMITTED: YES❑ NO FIXTURES 7 FLOOR—I DSM f 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ • CROSS CONNECTION DEVICE ' DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _ DISHWASHER ' DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I' LAVATORY ROOF DRAIN t SHOWER STALL _ ' SERVICE/MOP SINK _ • TOILET • URINAL WASHING MACHINE CONNECTION • WATER HEATER ALL TYPES 1 WATER PIPING - OTHER j. INSURANCE COVERAGE I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch,142 YES LYNO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE t30X BELOW LIABILITY INSURANCE POLICY [2' OTHER TYPE INDEMNITY L] BOND Q 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 walves 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,a PLUMBER-GASFITTER NAME Andrew Levesque LICENSE# PL15162 GNIATtrigg MP' MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC(# 3944 - COMPANY NAME Harwich Port Heatinci&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 andyahphc(Ic.com • • • (,R e IF Y I I _� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK South Yarmouth 9/25/2017 CITY MA DATE PERMIT# L � � /0 77 JOBSITEADDRESS 43 Cove View Drive OWNER'S NAME Sellers GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ 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 FRYOLATOR FURNACE GENERATOR 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L/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 at 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# PL15162 GNATU MP LV1 MGF Kir JP❑ JGF❑ LPG'❑ CORPORATION❑# PARTNERSHIP❑# LLC '# 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@hphcinc.com