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HomeMy WebLinkAboutBLDG-22-002198 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e CITY YARMOUTH MA DATE October 18,2021 PERMIT# BLDG-22-002198 If JOBSITE ADDRESS 2120 HEATHERWOOD OWNER'S NAME Ronald Hawes G OWNER ADDRESS 2120 HEATHERWOOD YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 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 El 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 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 0 JGF 0 LPG! 0 CORPORATION❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections(a efwinslow.com S310N M3IA3ii NVId #11WN3d $:33d LWWH d 3H1 SY S3A83S NOIlVOIlddV SIHI oN saA S310N N01103dSNI 1VNId AlNO 35l 210103dSNI 210d 30Vd SIR' S310N N01103dSNI SVJ HJl021 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q—f = cua r: CITY YARMOUTHPORT 1 MA DATE 10/7/21 PERMIT # Z, Z— ?Jig : y I JOBSITE ADDRESS 2120 HEATHERWOOD DRIVE OWNER'S NAME RONALD HAWES G . . OWNER ADDRESS SAME KK m^ �� A TEL 5087892090 y' FM TYPE OR OCCUPANCY TYPE COMMERCIAL: i EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: i PLANS SUBMITTED: YES NO , ,, APPLIANCES Z FLOORS---• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER . BOOSTER E('; CONVERSION BURNER COOK STOVE 3 DIRECT VENT HEATER VN, DRYER , .3 FIREPLACE l/V FRYOLATOR ; FURNACE 1 GENERATOR GRILLE (t INFRARED HEATER ('t LABORATORY COCKS r MAKEUP AIR UNIT ► OVEN --6 POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER . WATER HEATER OTHER GAS PIPING___.._ ... '..:cv<v4lNSWd c... ... .itlNNl'dW.,'AWWU6tA\NiAWKA<KWhN d\Y l:.: —..• 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 ri 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 I a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0 PLUMBER-GASFITTER NAME STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP i MGF JP JGF LPGI j CORPORATION # 3281 C PARTNERSHIP # _ � LLC # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE 2 CITY SOUTH YARMOUTH STATE MA JZIP' 02664 TEL 508-394 7778 FAX 508-394-8256 j CELL N/A EMAIL INSPECTIONS@EFWINSLOW COM •