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HomeMy WebLinkAboutBLDG-22-006123 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �-,� CITY !YARMOUTH MA DATE 'April 25,2022 I PERMIT# BLDG-22-006123 JOBSITE ADDRESS 163 SEAVIEW AVE OWNER'S NAME IADAMS ALISON J G OWNER ADDRESS 163 SEAVIEW AVE SOUTH YARMOUTH MA 02664 TEL I TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ RESIDENTIAL CLEARLY NEW: ❑ RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ 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 1 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 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 BOND 0 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 I LICENSE# 112298 I MP© MGF ❑ JP❑ JGF El LPG! 0 CORPORATION 0# I SIGNATURE PARTNERSHIP ❑#I ILLC ❑#1 COMPANY NAME: 'STEPHEN A WINSLOW I ADDRESS. 18 REARDON CIR, CITY IS YARMOUTH I STATE IMA I ZIP 1026641207 I TEL I FAX 1 I CELL 1 I EMAIL Iinspections(rD.efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "it I_ - CITY YYrr� �5QtA.10 .� MA DATE a2 �-7-- PERMIT# 2'i- (o l - JOBSITE ADDRESS{Lo3 51.Wi euJ 4,e 5 Ytwolp M �WEER NAME r AL+`ua A GOWNER ADDRESS �c ' Aj TEI (506)-tr'.- .O FAX— TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT EDUCATIONAL RESIDENTIAL El CLEARLY NEW:A RENOVATION:La REPLACEMENT:[j PLANS SUBMITTED: YES{ NOW APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER „ 1 ? y m BOOSTER I T -(i _ _.1 4 .',F jib• I COOK STOVE , r FIREPLACE � ..-�� NIIIIIMIIIIIIIIIIIIIISEIIMIIIIIIIIIIIIIII Mill.OM Mg FRYOLATOR °` R FURNACE _.- 1 - , I GENERATOR [ r�- a , =` 1� 1 _ -i ®w ' a ' � ' °L GRILLEwF- 6 INFRARED HEATER - -- LABORATORY • COCKS ice.- a 1 .� .i €�--�. .a..,E: 11 -�.I POOL HEATER ;. O •' _ r-® i 2 TEST , � 4 UNIT HEATER i � - � UNVENTED ROOM HEATER I _ _ - , WATER HEATER I' 1 ri 1. OTHER ( . r_ i .. .,-_ w., � . E , � `r- ,„._ u INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1-2 f 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 s. 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 L-. AGENT r A 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 complianc a P rtine Massachusetts State Plumbing Code and Chapter 142 of the General Laws. provision of the PLUMBER-GASFITTER NAME STEPHEN WINSLOW ""� I , I _-__- SIGNATURE - ---- ---. � , a LICENSE# MP LL,I MGF D JP ri JGF 13 LPGI; CORPORATION i! #!3281 C PARTNERSHIP 1,_ #1 'LLC, # COMPANY NAME:E F WINSLOW PLUMBING&HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH , -_ �� STATE 1 MA i ZIP}02664 m TEL 508 394 7778 ' �� .... j�FAX i 508 3948256CELLL N/A jEMAIL:INSPECTIONS@EFWINSLOW COM '_ _ _ n4 1