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HomeMy WebLinkAboutBldg-22-001626 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ''' CITY YARMOUTH MA DATE September 21,202 PERMIT# BLDG 22-001626 If JOBSITE ADDRESS 415 ROUTE 6A OWNER'S NAME John Grady G OWNER ADDRESS 415 ROUTE 6A YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ 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 0 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© MGF 0 JP 0 JGF❑ LPG' 0 CORPORATION❑# PARTNERSHIP 0# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionst7a,efwinslow.com , ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ FEE: $ PERMIT# PLAN REVIEW NOTES y f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK alit _ ..• CITY YARMOUTH MA DATE 916/21 W' .....J PERMIT# 2:1-- (co.tc JOBSITE ADDRESS[415 ROUTE 6A,YARMOUTHPORT OWNER'S NAME JOHN GRADY GWPO—BOX 22,YARMOUTHPORT,02675 TEL 8027607837 FAX [ 1 TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL j j RESIDENTIAL LLI �, CLEARLY NEW:. RENOVATION:Li REPLACEMENT:Li PLANS SUBMITTED: YESL-11 NO APPLIANCES 1 FLOORS—) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -.- � t. _ ...._ �... - .._y�. :. BOOSTER . . �. CONVERSION BURNER COOK STOVE OR ' .,., I DIRECT VENT HEATER rt\ DRYER es' � r r � FIREPLACE Oo FRYOLATOR 1 . -.. f .,n FURNACE . a GENERATOR _ ," iiimirs.if 1 ' r uN GRILLE t. .: ' INFRARED HEATER mot, t z tr— 1 LABORATORY COCKS i � MAKEUP AIR UNIT MC n al OVEN ' I I 1 l _. . ,j. . F mm. , POOL HEATER -- ROOM I SPACE HEATER ROOF TOP UNIT - �i 1, TEST ._a 1E UNIT HEATER 1 UNVENTED ROOM HEATER Ininlitill WATER HEATER __, OTHER i ,.. .. «............xi. >. _ ^ _ .. .....vcK s�ew.. nxww.awwwwwerew� __.. ,q.,...a.. ......... - .. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 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 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 LJ AGENT E .` 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 compliancnc a'Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i1 • / r PLUMBER-GASFITTER NAME STEPHEN WINSLOW 'LICENSE#'12298 WLL SIGNATURE MP L,f,j MGF JP Lj JGF r LPG!i� CORPORATION i+ #!3281C i PARTNERSHIP] I#' � LLC M# COMPANY NAME E F WINSLOW PLUMBING&HEATING I ADDRESS[8 REARDON CIRCLE CITY SOUTH YARMOUTH 7 STATE MA 'ZIP 1 02664 1TEL 508-394 7778 FAX 508 394-8256 CELL[A_ _*_ EMAIL] INSPECTIONS@EFWINSLOW COM