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HomeMy WebLinkAboutBLDG-22-001879 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK b CITY YARMOUTH MA DATE October 04,2021 PERMIT# BLDG-22-001879 JOBSITE ADDRESS 36 MERCHANT AVE OWNER'S NAME MILLER DENNIS G OWNER ADDRESS MILLER LAURA 36 MERCHANT AVE YARMOUTH PORT MA 02675 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:❑ 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 ❑ NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER OF INDEMNITY 0 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❑ LPG' ❑ CORPORATION❑# PARTNERSHIP El# LLC ❑# 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 M3IA321 NVId #1IV d $:33A ❑ 0 11161H3d 3H1 SY SaA83S NOLLv011ddv SIHl oN saA S310N N01103dSNI 1VNIJ K1N0 3Sf1210103dSNI 210J 30Vd SIH1. S310N N01103dSNI SVO H0f108 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK q --=,...-__F-i-=---..,_ — � �=r CITY YARMOUTH MA DATE ` 9/30/21 PERMIT # ` . ? ( E 1 c/ - ‘ik,___p__ JOBSITE ADDRESS 36 MERCHANT AVE, YARMOUTHPORT OWNER'S NAME DENNIS MILLER t-... G ,_____ OWNER ADDRESS SAME TEL 5086197633 FAX TYPE OR ;3- OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: 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 p BOILER w BOOSTER CONVERSION BURNER COOK STOVE ek.1 DIRECT VENT HEATER DRYER Z FIREPLACE _ FRYOLATOR FURNACE 1 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 GAS PIPING ........ ...... 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 i `I 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 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 _aws. 0 PLUMBER-GASFITTER NAME STEPHEN WINSLOW ` LICENSE # 12298 SIGNATURE MP i MGF JP JGF LPG' CORPORATION i # 3281C PARTNERSHIP # LLC # ... •-•-. ........ltim'W�WirSi'dPoW:1k1:WiN2! ......:..... ...... .. ..............r.wmn:..w....n.van.w.ruvww..w. COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ' ADDRESS 1 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778 FAX 508 394 8256 CELL: N/A EMAIL! INSPECTIONS@EFWINSLOW.COM • - }i