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Home My WebLink AboutBLDG-22-003070 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' CITY YARMOUTH MA DATE November 29,202'PERMIT# BLDG-22-003070 JOBSITE ADDRESS 118 DAISY LN J OWNER'S NAME BROUTHERS ROBERT R JR G OWNER ADDRESS BROUTHERS BRIAN 18 DAISY LN SOUTH YARMOUTH MA 02664 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL❑ RESIDENTIAL El PRINT CLEARLY NEW: 0 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El OTHER OF INDEMNITY❑ 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 —1 LICENSE E 12298 SIGNATURE MP El MGF El JP 0 JGF El LPG! ❑ CORPORATION El# PARTNERSHIP El# LLC El A COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspectionstUtefwinslow.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE: $ PERMIT# PLAN REVIEW NOTES 4- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q1 la ; --..______-__. L2 '-�"•�� CITY YARMOUTH MA DATE 11/16/21 PERMIT # JOBSITE ADDRESS 18 DAISY LANE OWNER'S NAME ROBERT BROUTHERS GOWNER ADDRESS SAME TEL 5086802571 :FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ,:� EDUCATIONAL ,. RESIDENTIAL CLEARLY -..... NEW. RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES Z FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER Vs— COOK STOVE } DIRECT VENT HEATER DRYER FIREPLACE �,: FRYOLATOR FURNACE °' GENERATOR .3 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I NO —11 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY , OTHER TYPE INDEMNITY ' ary 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 —1 AGENT .::. 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 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C\ -,0 --. ........"--- PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP MGF JP JGF ] LPGI : CORPORATION # > 3281C r PARTNERSHIP sa ,,,# I LLC # 3uN1tdlNh�`NNAU&� k .... COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE , CITY ; SOUTH YARMOUTH I STATE MA ZIPI 02664 TEL 508-394-7778 FAX 508-394-8256 CELL N/A 'EMAIL' INSPECTIONS@EFWINSLOW.COM x.,