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HomeMy WebLinkAboutBLDG-22-001891 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �,' CITY YARMOUTH MA DATE October 04,2021 PERMIT# BLDG-22-001891 JOBSITE ADDRESS 39 OLD MAIN ST OWNER'S NAME STUBBINS SARA WATSON TR G OWNER ADDRESS C/O FRANK N.&CLARA WATSON 39 OLD MAIN ST SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ 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 FIREPLACE FRYOLATOR FURNACE 1 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 ❑ 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© MGF ❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# Lc ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsna,efwinslow.com . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a ' = ie® i gt=kk= CITY YARMOUTH j MA DATE`9/29/21 PERMIT# 22-- tS ( JOBSITE ADDRESS 39 OLD MAIN STREET OWNER'S NAME FRANK&CLARA WATSON GOWNER ADDRESS SAME TEL 5083947319 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL, i EDUCATIONAL RESIDENTIAL i�'' PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES i '. �s NO, (1) APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ ti ( CONVERSION BURNER COOK STOVE ko DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS ` MAKEUP AIR UNIT I it OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT 1 TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER GAS PIPING INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES i 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 €.. 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 f- AGENT '2 .: 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 a Pprtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. if/-• .....<..�- r PLUMBER-GASFITTER NAME STEPHEN WINSLOW !LICENSE#1,12298 1 SIGNATURE MP I ± MGF JP' = JGF LPGI CORPORATION i #-3281C PARTNERSHIP #� LLC # COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING j ADDRESS:8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP 02664 jTEL 508-394 7778 FAX 508-394-8256 I CELL N/A C._. .......... mm EMAIL ECTIONS@EFWINSLOW.COM