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HomeMy WebLinkAboutBLDG-23-004203 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH t MA DATE January 30,2023 PERMIT# BLDG-23-004203 __ E / JOBSITE ADDRESS 12 LESLIE LN OWNER'S NAME Roger Smith G OWNER ADDRESS 12 LESLIE LN YARMOUTH PORT MA 02675-2240 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: El 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/SPACE HEATER ROOF TOP UNIT TEST 1 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 ❑ OTHER OF INDEMNITY 0 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. 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 © JP 0 JGF❑ LPG( ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: 'STEPHEN A WINSLOW ADDRESS. 18 REARDON CIR,8 REARDON CIR CITY IS YARMOUTH STATE MA ZIP 102664 TEL 15083947778 FAX I I CELL I I EMAIL Iinspectionsna.efwinslow.com MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i r=,, CITY Yarmouth 1 MA DATE 1I26/23 1 PERMIT# JOBSITE ADDRESS 12 Leslie Lane OWNER'S NAME [Roger Smith GOWNER ADDRESS same 1 TE 774-353-6 TYPE OCCUPANCY TYPE COMMERCIAL LPRINT .] EDUCATIONAL RESID NTI L AN 26 2023 CLEARLY NEW:LiRENOVATION:Li REPLACEMENT:Li PLANS1q UEMITTED: YES ID NO APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 i B1 jahlf1�� t3L1 IT 1 1 r.:4.... .----�� BOILER , BOOSTERMINNIIIIIIIII1501151111111111I11111111111111111111111.111.11MM CONVERSION BURNER i. 3 1[ COOK STOVE 0111_101111.1111.111111111 Mg OM Man al.11111111.11111.111 air . DIRECT VENT HEATER ow gm ' `_ .,. am" DRYER11111$10;110-1M1 IIIMIIIIIISIIIIIMIIIMIIIIJIIMNIIIIIIIIF MAW —1 FIREPLACE NM .mom ._.._:: _ .. hr. .: ..- . 1 �., FRYOLATOR s FURNACE 1 e I y,d GENERATOR Mil _ ,_'.... 3 - GRILLE INFRARED HEATER ar LABORATORY COCKS rignieMAKEUP AIR UNIT :. = ,.- 1 OVEN POOL HEATER ROOM I SPACE HEATER 1 1 ROOF TOP UNIT TEST t. I UNIT HEATER MI I I UNVENTED ROOM HEATER ` $ _. ' ___. i 1 WATER HEATER (- OTHER ... INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO Li I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 1,j 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 D AGENT i 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►YPprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ( %1 • // PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE# 12298 SIGNATURE MP l MGF LJ JP , JGF LPGI CORPORATION # 3281C PARTNERSHIPLJ#I LLC U#L, COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING J ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH _J STATE MA JZIP 02664 JTEL 508-394-7778 FAX 508-394-8256 j CELL NIA EMAIL INSPECTIONS@EFWINSLOW.COM