HomeMy WebLinkAboutG-20-2202 __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY YARMOUTH MA DATE 1 n/10/201 o PERMIT#b 'l ZOg
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OUTH SHORE DRIVE, OWNER'S ADDRESS-COT 1AGE 3 NAME RED JACKET BEACH INN
G OWNER ADDRESS TEL 508.398.6941 FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION:"❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-4 8SM 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 Ei NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El 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 nd 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 compl' ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A. WINSLOW LICENSE# 12298 SIGNATURE
MP Ef MGF❑ JP❑ JGF❑ LPG!❑ CORPORATION l# 3281C PARTNERSHIP 0# LLC❑#
COMPANY NAME EF WINSLOW PLUMBING& HEATING ADDRESS '8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL accountspayableftefwinslow.com
WORK ORDER 513673$50.00 �� l�
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