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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
?`163= ' CITY/TOWN Yarmouth MA DATE 6/28/17 PERMIT
#/IO OOCv 6,2
JOBSITEADDRESS 17 Nickerson Farm Way OWNER'S NAME Davenport Reality
P . OWNER ADDRESS South Yarmouth TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El
PRINT F
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO El
FIXTURES Z FLOOR—I BSM 1 2 3 4 b 6 7 8 9 10 11 12 13 14
BATHTUB
• CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM _
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM i'
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN .
INTERCEPTOR(INTERIOR) _ _
KITCHEN SINK
LAVATORY
ROOF DRAIN ,
SHOWER STALL _
SERVICE I MOP SINK _
TOILET
URINAL _
WASHING MACHINE CONNECTION
• WATER HEATER ALL TYPES 1 _ _ _ _
WATER PIPING
OTHER _
INSURANCE COVERAGE
I have a current liability insurance policy or Its substantial equivalentwhich meets the requirements of MGL,Ch.142 YES [YNO 0
Fi
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW h
LIABILITY INSURANCE POLICY licZ 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 El AGENT.0
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 -� ""`'i�J GW TA U -
Andrew Levesque LICENSE# PL15162
MP y MGF El JP❑ JGF El LPGI El CORPORATION❑# PARTNERSHIP 0# tic g(# 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(a7hphclIc.com
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
57.7wW-7 Or!
CITY Yarmouth MA DATE 6/28/17 PERM IT#1&O/' D00(./
JOBSITE ADDRESS 17 Nickerson Farm Way OWNER'S NAME Davenport Reality
GOWNER ADDRESS South Yarmouth TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑x
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO fiki
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/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER i
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Dr/NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g 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 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 g MGF Ez 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