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HomeMy WebLinkAboutBLDG-20-001144 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK YARMOUTH ,,g r/ CITY MA DATE 08/27/2019 PERMIT#/�L,/�-a°'(1° JOBSITE ADDRESS 10 BLUEBERRY PATH OWNER'S NAME MCDONOUGH, CAROL G OWNER ADDRESS YARMOUTHPORT TEL 617.877.5560 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION: ❑ REPLACEMENT:® PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS-0 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 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 121 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY RI' OTHER TYPE INDEMNITY ❑ BOND El 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 El SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are t 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 co nce 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[2i MGF 0 JP❑ JGF❑ LPGI ❑ CORPORATION[z# 3281C PARTNERSHIP❑# 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 accountspayable@efwinslow.com WORK ORDER 511175$40.00 Q/f , LO %' -, • .7 The_ :Cam11104iir66B11 xr, if s064.0$#s � ,t ��� ,1:-..T, . - 0ejv4-4it�r.,�iridusu ,�igns „ r 104 it e . i1 �' Q . 1\ ? 't i .Balton, 01714-2U17 6rlt Compensation Insurancg id w erdDotit ctt4raElEleoisins7P,lumbers.; >�E 1 d a rc . A- an 1 :.,. .::)��f �Y #iNS` W P UMB1N &W 1`#NG o,,* i es10f1g 1r L1P., ----7-7-'--".-.Z Vi&tiolo0r t,M&kk 64 ;Elrod,#;~t osao-.Its :: ,tea * 1 Plt 6QY: T�0510rpt4**P* " \-- . I':ir.Y. am itt With; „.emp[oyee.s(fultai►d/orpart..timq •` 7 New t�tistcuction Y "- Yhsva '+rraipltiy es idil f`orns:in � awl tt ce aeguiF+ed4 ' -TC' i'. spa *iu pr 04.0111 a tayes?ffw* ct p lnturaW ne ireePt 9 [,D`Decnoli ion \, 1Cis+ 6 1d[ � �*4dt ti p, \ bk t aiC uav �ts obiabu or reF sb ' Lavin 110;; en l� .tot s ..i_,011 .s°wtdt na nupleyeec,. 12KEIPtumlaiag ti*P:r* �A ri 50,1 0t u t►�1 ad y�ektheub=oonkamo*-i oa itta dsties l3 • a ,T� +�0ofiaW1u 1 iiia�hvevoros'im .�t • i ►ts' _. b.p. o0p�tt ���c�� of�?� La 14 _ a.� .14.. r s s'-� � `''nb ngs a.thenhhue o eec�+ot*sctors us autban ta41CWd fs0.1*dr g4:sue, �C* R_ 0di`Gfib **p*an: tt°r#!1>aheee*w7ntal6#a�ttt.dP,tite' 14ctPrat�witilatLta"wlietfucoi'i�E-liwteantlU+eb,�iavns, tfa>i� w , ataEr er rot li f Vt14-10.ikiii0compensation iiisurancejoi li !erg: Beto*WiiipiIU "a't t .i Atiat g4 , 64$ ,f 7lW MiJTPN N:4• W4.0E C©MP-ANX. Poftcy#of 1e1f-.ltis,Lid #y'1:9u9A Ei ii ion Y7t tc901101/��:... ...:... :. ' e e*ity t►Y vi 4�MitiMintsationliaife30-Jeclanntioti p*ige(slbbwingthe policy towbar d anti n da . Pact t s*Cu v e it 'Ufldbt`MGL e--L32,.fitkira7ciOntri017 violation-putliahable by a finnui3* '1, ' anti/or one earanz)n n nt,-44.weB:ss civil.:penalties in the form of a STl'P'W QRD and n oity fup to woo,a dayyagaut ho+v o1at0t: copy ethis'statt statement may be te.t*tr ed`.to tote Oft t*.011 vestigaftona.of tl T . ix i u t*: .rr.. _0 i /�i ;; .�T •'- :1- , " of e', ikat. '.._ / p v,"__ l lstrReacor l f7. d fj'3 ''1 "o4,IJo i of tv inthis.area,to be comp it bar crty"vr toivit o ic1aL": Ctty or`Tow.n Permiit/License# ; L Board4Heaitit 2.BtiIidtngDe met nt 3.City/Tiiwir.Clerk 4.:Elecirical<Inspe for°S.�Pl0mbinlanSpentor . iCq tPertent,,_; � - Phone# -