HomeMy WebLinkAboutG-13-739 JI MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 1If /120(L .,,,, Q.( MA DATE __ PERMIT# &19-7'37
• JOBSITE ADDRESS' i / U / r
1 G / _ OWNER'S NAME I�
OWNER ADDRESS [Lisa-
_..5 ..,_ JTEL S3_11,
�7O7 FAX1 —_
TYPE OCCUPANCY TYPE COMMERCIALi„„] EDUCATIONAL[J RESIDENTIAL Gd'
CLEARLY NEW:D RENOVATION:LI REPLACEMENT:V PLANS SUBMITTED: YES❑ NO[J
APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
—1—I 1 7
BOOSTER _ I __.._I ._ I I _ I l -._..__I f _..._ I _ ____I'_____I _ _ I ..--.I ..___I
CONVERSION BURNER _I ._...__7 _I J _-._J _ I ____ _ _._I
COOK STOVE
DIRECT VENT HEATERt I
DRYER -.--. —_J t�_ I �I �.1 _J _. J l _ I ___I
FIREPLACE f I J I ' I _1_ f
1 _ _J__
FRYOLATOR
FURNACE —.— _ ! I' I ilI �,.__. [ „! __ I ___ ! _._ �_I .J
GENERATOR — ---5 + J.
1 .
GRILLE ilitlitillia
INFRARED HEATER I I
LABORATORY COCKS
-17111
MAKEUP AIR UNIT I I
OVEN
POOL HEATER
ROOM ISPACE HEATER
ROOF TOP UNIT .____1
TEST
UNIT HEATER awl
UNVENTED ROOM HEATER —__I _!
WATER HEATER_,_,,_____-______.__ J I I
I _ i 11 1 1 I _t
I , . I .__ • I I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch.142 YES LU NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY 1..„1 BOND (i
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 E ONLY: OWNER AGE
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 a ufat to the b t of my edge
and that all plumbing work and installations performed under the permit issued for this application will be In compliance i provisi• e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ritephen A.
Winslow I LICENSE#;12298 SIGNA URE
MP LA MGF Li JP jTj JGF LPGI rj CORPORATION(,j#F1281C 1 PARTNERSHIP D# J LLC #E
COMPANY NAME'-E F.Winslow Plumbing 8 Heating Co Inc. I ADDRESS 18 Reardon Circle
CITY South Yarmouth STATE r—MA f ZIP F626_51____.]TEL 1508-3944778
FAX 1508-394.8256)CELL NIA ______IEMAI & courts e in nw',;i
111LLCk �/iao - f/3 at 9 Ll2If
By BUILDINg Pur
C
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Ya No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT S
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