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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"�® tbCITY �� _ �T MA DATE D3/OZO3J PERMIT# 6/9— 812
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JOBSITE ADDRESS',)4 et jeXand e r A r I OWNER'S NAME ,Ji c ' „ , _.J
GOWNER ADDRESS ITEL_n_0357 -- __ -I
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL _1 RESIDENTIAL
CLEARLY NEW:_J RENOVATION: _J REPLACEMENT: V PLANS SUBMITTED: YES _I NO _._!
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _ 1_ __J__4 J _A __J---•-J -J-- J _ J _ _ _t__ 11
BOOSTER ^ J'_ 1 1' 1 _.J_ _ J J _.1 J_ J _ .._1_ .J _ I _.._l
• CONVERSION BURNER '____1___.1 __I f J - -J --I- J - J ' -`-J`- ---J " J
COOK STOVE _ 1_ J _ 1 J J____J___ J_ _J ____I __. J__J _J J ._. 1_.__ J
DIRECT VENT HEATER ___"J_ J _,.J" J_ . 1 J .._1 J J J . --J" JJ 1
DRYER _J J __A —1 .L J ..__1 J _ 1 J - J _J_ 7 __..1 __� 1
FIREPLACE _ _-.1____J_ ..J_ A 1. .._J ._._I ..... J _ ,..1 _. 1 _J_ J__."..J.__,J
FRYOLATOR ___J_" ._J 1—_J ____1 rJ"____J _-1 _ J __J___J __1__J___J__A
GENERATOR 1_4,4_1 I 1i___1'"_"J __ J _I_- 1 I J .__J _... J ,_.J__,_J _J
GUNNRAT _ J�__,_1 1 J J_ J. J J___J,,_._J _._1
GRILLE _F1—.J_.. _1, �.._ _.1
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INFRARED HEATER ,� - ,� J - J J -J
LABORATORY COCKS 5 I 1 k. I I' k' _ 17 _1 J.. 1 1 _, 1 1, __I
MAKEUP AIR UNIT 1_--- J L,-®� e ,_1, _Jr_ ,.J ._. 1 __.I _ J . _ 1 J _ J ___.J
OVEN __._ E__Al.. 1 J __i 1 ._ l A .1 I J I I •_J
POOL HEATER J, _; _ 1 I _t . 1 _ ____I ..; __ .. 1_ _..' -. J _ J .
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ROOM I SPACE HEATER 1_ J J 1 - . -J _-. --- -J __ J _ 1 - -
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0 ROOF TOP UNIT j a 1 1 J 1_ 1 _ J . J - J _J 1 .- J . _!
_J _J _ __J___J ___J . 1 .._1_ 1 __- J I
UNVENTED ROOM HEATER I-_-"J�� � m� J J J 1_____1 `J I __.1 1
TEST k
UNIT HEATER �:.___J J
_ J . L 1 . „ I J_._- J J _ . 1 1 _ J __I _J __J _I
WATER HEATER 1' .} I G J _ 1 I .- I J._ 1_._._1 , .J . 1
OTHER I__ _1 1 _1_ _I_ _1 J J , _ 1 J I .._; J ' .. .1
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NJ - INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1!I NO _".i
M I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LL J LIABILITY INSURANCE POLICY :!1 OTHER TYPE INDEMNITY _,.J BOND 1-_1
t _ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1/4.( ) Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK : OWr ' '7 -_1 AGr ' .. I
SIGNATURE OF OWNER OR AGENT
OI hereby certify that all of the details and Information I have submitted or entered regarding this application are true a c rate to e best of owledge
. and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance all Pe ne•t provis• of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
C.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW ...- . LICENSE# 12298 I SIGNATURE
MP ;.J MGF _j JP _,i JGF•_I LPGI:—I CORPORATION _J# 3281 { PARTNERSHIP .J# __...,._ J LLC ,,J# .,.,
COMPANY NAME EF.WINSLOW PLUMBING&HEATING COj ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH-_... _ 1 STATE MAIZIP 02664 _-.__ ITEL 508.394-7778 ____T__,..,- .
FAX 508-394.8256 CELL.__.______ EMAIL ACCOUNTSPAYABLE@EFWINSLOW,COM ..___ - -1�_S J �pk-„ g' 1}" " g1• MAR �2�13 11...L,
a t ielY3W Olio
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By....--.
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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