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HomeMy WebLinkAboutBLDG-21-001114 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE September 02,202 PERMIT# BLDG-21-001114 JOBSITE ADDRESS 5 ALEXANDER DR OWNER'S NAME MILLS KENNETH R G OWNER ADDRESS MILLS MARTHA M 5 ALEXANDER DR YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ 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 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 El NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ 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 LICENSE# 12298 SIGNATURE MP© MGF ❑ JP❑ JGF❑ LPG' ❑ CORPORATION El# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: E.F.Winslow Plumbing&Heating ADDRESS. 8 Reardon Circle, CITY South Yarmouth STATE MA ZIP 02664 TEL 5083947778 FAX 5087603766 CELL 5083947778 EMAIL S310N M3IAMI NVId #11W213d $:33d 7L7Zl1t 1u� ❑ 0 111%13d 3H1 SV S3A213S NOI1VOIlddV SIHI ! .72/.-4V oN saA S310N N01103dSNI IVNId WINO 3Sl 210103dSNI HOd 3OVd SIH1 S310N NO1103dSNI SVO HOflO