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HomeMy WebLinkAboutBLDG-22-001593 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK --k-___.1 = BLDG-22-001593 ,� CITY YARMOUTH MA DATE September 20,202 PERMIT# t®I JOBSITE ADDRESS 68 PARK AVE OWNER'S NAME AGOSTINELLI DAVID J G OWNER ADDRESS AGOSTINELLI RITA A 12 ELM ST NATICK MA 01760 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: 0 RENOVATION:❑ REPLACEMENT:0 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 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 El 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 Stephen Winslow LICENSE# 12298 SIGNATURE MP© MGF ❑ JP 0 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME: STEPHEN A WINSLOW ADDRESS. 8 REARDON CIR, CITY S YARMOUTH STATE MA ZIP 026641207 TEL FAX CELL EMAIL inspections a7etwinslow.com S310N M31A321 NVld #1101213d $:33d ❑ ❑ 11W213d 3H1 SY S3A213S NOLLVOIlddtl SIHI oN se), S310N NO1103dSNI TYNId AlNO 3Sfl i10103dSNI 210d 3Ovd SIHI S310N NO1103dSNI SYO HOflOil MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY YARMOUTH MA DATE 9/13/21 PERMIT # — I � � JOBSITE ADDRESS 68 PARK AVE, W. YARMOUTH OWNER'S NAME ` DAVID AGOSTINELLI LJ OWNER ADDRESS 12 ELM STREET, NATICK MA 01760 TEL 5086542544 FAX TYPE PRINTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ` RESIDENTIAL � CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES - NO APPLIANCES Z FLOORS-0 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 e : GENERATOR -- GRILLE 4 . 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 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 ,k 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 a P rtine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME z STEPHEN WINSLOW LICENSE # 12298 SIGNATURE MP MGF JP JGF LPG11 CORPORATION # 3281C PARTNERSHIP #II LLC # COMPANY NAME: E.F. WINSLOW PLUMBING & HEATING ADDRESS 8 REARDON CIRCLE CITY SOUTH YARMOUTH I STATE MA I ZIP 02664 TEL I508-394-7778 FAX 508-394-8256 CELL N/A ,EMAIL INSPECTIONS@EFWINSLOW.COM