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HomeMy WebLinkAboutBLDG-22-001527MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK G TYPE OR PRINT CLEARLY CITY IYARMOUTH I MA DATE ISeptember 16, 202 PERMIT # BLDG-22-001527 JOBSITE ADDRESS 153 LEWIS BAY BLVD OWNER'S NAME JDAMICO JOSEPH A TRS OWNER ADDRESS DAMICO ZABELLE G PO BOX 41 HOLDEN MA 01520-0041 1 TEL OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL I 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 ❑ OTHER OF 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. 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 iStephen Winslow LICENSE # 12298 SIGNATURE MP ©MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION [:1 # PARTNERSHIP ❑ # E=LLC ❑ #� COMPANY NAME: ISTEPHEN A WINSLOW ADDRESS. 18 REARDON CIR, CITY S YARMOUTH STATE = ZIP 026641207 TEL FAX I] CELL EMAIL inspections a(d)efwinslow.com S310N MM3iJ NVId # 11W013d S :33d ❑ ❑ lIW?J3d 3H1 SV S3A83S NOIlV011ddV SIHl ON SOA S310N N01103dSNl lVNld AINO 3sn 801 3dSNl'dOd 30Vd SIHl S310N NOIlO3dSNl SVO Homi MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i CITY I YARMOUTH MA DATE 9/8/21 PERMIT # JOBSITE ADDRESS 53 LEWIS BAY BLVD, WEST YARMOUTH OWNER'S NAME JOSEPH DAMICO OWNER ADDRESS SAME TEL' 5087751889 FAX , TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ` PLANS SUBMITTED: YES NO, APPLIANCES Z 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 FI IRnIp('F ' 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 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES " 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 vWNcR',S NSURANCE 4;AiVER: 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 '. 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 ay�PP rtine 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 LPGIa CORPORATION # 3281C PARTNERSHIP:,J#LLCq"#' COMPANY NAME:` E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH STATE I MA �i ZIP 026' TEL 1508-394 7778_ � FAX1508-394-8256 CELL: NIA EMAIL' INSPECTIONS@EFWINSLOW.COM