HomeMy WebLinkAboutBLDG-22-002201 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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BLDG-22-002201
,ki,F CITY YARMOUTH MA DATE October 18,2021 PERMIT#
JOBSITE ADDRESS 135 CAPT BACON RD OWNER'S NAME JOHNSON VILMA M
G OWNER ADDRESS 135 CAPTAIN BACON RD SOUTH YARMOUTH MA 02664-2849 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL
PRINT
CLEARLY NEW: m RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 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 1
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
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER OF INDEMNITY El 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.
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 Stephen Winslow LICENSE# 12298 SIGNATURE
MP 0 MGF 0 JP 0 JGF 0 LPG! ❑ CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR,
CITY S YARMOUTH STATE MA ZIP 026641207 TEL
FAX CELL EMAIL inspectionsa.efwinslow.com
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Cji MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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(") _N1�� CITY YARMOUTH MA DATE 1 10/10/21 PERMIT#
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LMAJOHNSON
JOBSITEADDRESS,I
135 CAPTAIN BACON ROAD OWNER' NAMEVI
(/) G OWNER ADDRESS jSAME_ TEL 5087606761 FAX L_____!!! y
TYPE OR
OCCUPANCY TYPE COMMERCIAL! _" EDUCATIONAL RESIDENTIAL Li,„---;",
PRINT
CLEARLY -
NEW:; ' RENOVATION::. : REPLACEMENT:€...».ami PLANS SUBMITTED: YESEA NO'
APPLIANCES 1 FLOORS--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER s • u
BOOSTER L_a 1 ;� " i
fr CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
._ DRYER I'
rp FIREPLACE 16 I 1 - ..__. 1
V FRYOLATOR ! ` al 11 I 1 1f
FURNACE i.
GENERATOR 1
GRILLE ' ; _ € __ it xl : Jr
INFRARED HEATER ._ ' L� .. . j `,� _ �
LABORATORY COCKS * F 1
MAKEUP AIR UNIT ".". . 1 `7 . t 1 ',.� ., ' 4
OVEN a i, 4
POOL HEATER k 1f ,,
1 al
ROOM/SPACE HEATER 1 '' ( , 1 I '' i
ROOF TOP UNIT 1.. i ` C 4 I
TEST ... !
t
UNIT HEATER
4,
UNVENTED ROOM HEATER F. � 4' �' L � <.. .m 1 _.__.m
_ gym_ _
f :
WATER HEATER t � � '
OTHER 1 GAS PIPING _ w
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... �....,� - � ..,..,.—.. .. ..��,..»..e ....' .. ,.m...,� 1,..» ..:.�...,..�.w...m...w � T. g:.a....:,.,:.�,. -.....8.....«.«i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES sNO 11,
.
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Iij OTHER TYPE INDEMNITY BOND LI
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 :,:j 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 true and accurat to the b st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliant ayPP rtine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � 1 ,•li/...
PLUMBER-GASFITTER NAME I STEPHEN WINSLOW LICENSE#''12298 ( SIGNATURE
MP MGF'_m,2, JP: JGF fl LPG'1 CORPORATION I + #13281C s PARTNERSHIP i# t LLC ww #'
� , 1
COMPANY NAME' E.F.WINSLOW PLUMBING&HEATING
ADDRESS18 REARDON CIRCLE
CITY SOUTH YARMOUTH E STATE 1 MA _ZIP€02664 TEL 1508-394-7
FAX;508-394-8256 CELL,N/A EMAIL: INSPECTIONS@EFWINSLOW COM _._.._
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