HomeMy WebLinkAboutG-14-514 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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,Li •;q CITY �.r � _. (] �_} MA DATE II 'Z7- 13 �PERMIT
JOBSITE ADDRESS 26 / ,Loh Irt.�lu� (OWNER'S NAME94P4'16ekki C I
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OWNER ADDRESS � tyro/ti �r1 4-- I TEL 61:c ,; 7 nao IFAX -J ,..
TYPE OR OCCUPANCY TYPE COMMERCIAL`i EDUCATIONAL J RESIDENTIAL yt
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CLEARLY NEW:714 RENOVATION: -_I REPLACEMENT: ,._l PLANS SUBMITTED: YES-,J NO j
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UNIT HEATER 11/14111111011111111111111SIONIMINSINISSIONIIIIIMMINIIIIIIIM
UNVENTED ROOM HEATER imminammiliganissimomeggenager
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BUILDING Da•A• MEND Pleb,
hoe a current liability Insuranc.poliINSURANCE COVERAGE S•cy or its substantial equivalent which meets the requirements of MGL.Ch. 42 QrcS L1 NO _.i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1j
LIABILITY INSURANCE POLICY +J OTHER TYPE INDEMNITY ,-J BOND I_.-1
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.
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CHECK ONE Y. 4)WNER -_ 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 ac ate the •:-t of my kn• _••e
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance with a rtinen •rovislon of t,
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. k/"
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW j LICENSE# 12298 I SIGNATURE
MP ,#.1 MGF __i JP JGF _ LPGI __I CORPORATION - I# 3281 _ _ - PARTNERSHIP J# ,... 1 LW .-l# ___ .
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COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING COff ADDRESS 8 REARDON CIRCLE_
CITY SOUTH YARMOUTH ' _ ' STATE MA ;ZIP 02664 ____. TEL 508.394.7778 __ ___ __
FAX 508-394-8256_i CELL _-_- I EMAIL ACCOUNTSPAYABLEAEFWINSLOW_COM _ t
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ROUGH GAS INSPECTION NOTIS THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEEn PERMIT#
t PLAN REVIEW NOTES
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