HomeMy WebLinkAboutG-14-036 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
41l:t CITY '._ /9C/rzv_vti _ j MA DATtr�'D4 •/3 PERMIT# 'bilk.-
��" � 1
�'1 JOBSITEADDRESS Z/ CLftT 'OWNER'S NAME
„ •' /
G OWNER ADDRESS "L/ y ?az jfr , !!/1, 7j�� .71
/V l/ 7/7h ITEC FAX�_�_._J
N TYPE OR OCCUPANCY TYPE COMMERCIAL3 EDUCATIONAL _I RESIDENTIAL
• VI PRINT
CLEARLY NEW: -_-.I RENOVATION: ..) REPLACEMENT: Ir PLANS SUBMITTED: YES J NO
- / APPLIANCES 7 FLOORS-' BSM 1 2 3 Q 5 6 7 8 9 10 11 12 13 14
BOOSTER' BOILER
� �� 1 �� �1��
sn SS_ _I
CONVERSION BURNER ISISSINIUI1-I_I .INISSIIIIIA
COOK STOVE ilinal___11.11211___ __ __ � an
DIRECT VENT HEATER _1_MI���� .111_lSllIIIllllllll - -'
DRYER 0111ANIIIIIMIESL - -JMEI SIM MKS-___i MI --J
FIREPLACE __ni i fl � ---J - 1____1�1�J��
FRYOLATOR _JMIS 'II�II �® CJI_._:J
FURNACE 11..11®$1.�
nit ��rnSilltn��MIAMIENIN
GENERATOR Plaililiall0101111.01.�������a
�J
GRILLE IsMielle-41
INFRARED HEATER I 51J �JIIII'r-14 p01WLI.EMINIMIN
-LABORATORY COCKS �l•1.101J ..11s1 1.11uallZ 14M 41111Ill l
MAKEUP AIR UNIT FINi INIIIuiMIPIi W ll i llESI 1l EMJ11_____
OVEN � SiIiS� uw it .iaN
POOL HEATER S1M � � � 1
1111111111111
ROOM/SPACE HEATER � j •1
a
ROOF TOP UNIT allial �;���MISi '"r.. .:r�Jlt. � �
TEST MISiSI.1 ..Si IUMAf
UNIT HEATERiSSS --1.1 Is - . ' _M
UNVENTED ROOM HEATER _ ®____--1 _Wl�l l l ,�
WATER HEATER �M— _J __ISMS_
IS I --J5 1
OTHER I__111111111M111__._i l i S I111111111111_-- J - - -1 1
---.
J® }_.
INSURANCE CE OVERM__I _ J MI __J )_� .I :
I J _ 1 111.111111.111S
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I!1 NO ...i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY _tJ OTHER TYPE INDEMNITY ..J BOND I_}
r 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 s . I ` ': 'WN R AGEN. I
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 an'lltr . to th est of my V edge
and that all plumbing work and Installations performed under the permIt Issued for this application will be In compliance wi - Penin nt p 'vision • e ,.
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW I LICENSE# 12298., . SIGNATURE
MP j MGF __.I JP _I JGF_j LPGI__ CORPORATION _ 1# 3281 .;___J PARTNERSHIP _J# J LLC, u#
COMPANY NAME E.F.WINSLOW PLUMBING 8 HEATING COd ADDRESS 8 REARDON CIRCLE_
CITY SOUTH YARMOUTH STATE MA .1 ZIP 02664 TEL 508.394-7776_.-_ ,
FAX 50B-394.8256 'jCELL _.,_____- __REMAIL ACCOUNTSPAYABLE@EFWINSLOWCOM !
1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT C ❑
L
FEE: S PERMIT#
PLAN REVIEW NOTES
1