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HomeMy WebLinkAboutBLDG-22-005003 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .'.a CITY YARMOUTH MA DATE March 10,2022 PERMIT# BLDG-22-005003 JOBSITE ADDRESS 19 WILDFLOWER VILLAGE OWNER'S NAME Glenn Hansen G OWNER ADDRESS 19 WILDFLOWER YARMOUTH PORT MA 02675-1474 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL El RESIDENTIAL El PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT❑ 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 GENERATOR 1 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 El 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 ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionsRefwinslow.com S310N M3IA3N NVId #lIWN3d $:33d ❑ ❑ 1Ivi d 3H1 SV S3ALI3S NOIlV3IlddV SIHI ON SO), S310N N0I103dSNI 1VNId AlN0 3Sfl a0103dSNI NOd 3OVd SIR! S310N NOI103dSNI SVO HOfON MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r : t=1 CITY 'YARMOUTH.. ... . ..,.. . .,.:. ._, .,_. MA DATE 03/= 07/2022 J PERMIT # z Z " So��� JOBSITE ADDRESS 19 WILDFLOWER LN, YARMOUTH PORT, MA i OWNER'S NAME GLENN HANSEN G , OWNER ADDRESS 4415 BACK NINE DR, MIDDLETON, WI 53597 TEL(650)483-5875 F TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL v PRINT CLEARLY NEW: 71 RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS--. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER 1 BOOSTER 41 :_. CONVERSION BURNER _ _ COOK STOVE DIRECT VENT HEATER -- DRYER FIREPLACE 1 FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN } POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER 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 [ v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v j 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 AGENT Li 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 cornplianc i a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0 ? ., , ...pit PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE . .L.:,,,,J, MP - MGF JP JGF ; .....` LPGI 0 CORPORATION w # 3281C PARTNERSHIP #i LLC , , # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778 u . FAX 508-394-8256 CELL NIA -a .. EMAIL INSPECTIONS@EFWINSLOW COM