HomeMy WebLinkAboutG-14-331 F
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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42,It .._. 2. j I J.._"/"` )PERMIT# 6/t? ,9 /
ter- CITY ; ) bcifid (1)6,---� MADATE pF�d /3
LjT JOBSITEADDRESS 4I �O T6x-n elf Pe. OWNER'S NAME tb!ewer,0(",41/ I
G OWNER ADDRESS r ..4/ 'i6- 1 TEL •3p•25:1-DJ FAX J
TYPE OR OCCUPANCY TYPE COMMERCIAL L,,,I EDUCATIONAL }; RESIDENTIAL Tel
PRINT
CLEARLY NEW:[ J', RENOVATION:V REPLACEMENT:U PLANS SUBMITTED: YES;.,_{ NOD
APPLIANCES 2 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER 1 _1 ____I _,_ _I __..1 ._ ! _._.._ - . I
CONVERSION BURNER
I
COOK STOVE I 1 ' '
DIRECT VENT HEATER ._I _...I ; f ' \,
DRYER i 1J .._,_I __-._ __._..' _._. _' ..__ _ _
FIREPLACE
FRYOLATOR _ I I __ " .._ ! .____.,
FURNACE �._' ! ....___1 _._I _.__.._i
GENERATOR ' E.___'
GRILLE _
INFRARED HEATER1 ..-!
LABORATORY COCKS
MAKEUP AIR UNIT • ._-- _ _
OVEN = ;
POOL HEATER
ROOM I SPACE HEATER J _.__.i
ROOF TOP UNIT J _--` -_— -- I -_ '
TEST
UNIT HEATER - --
UNVENT :-.,.LL,g s�m-- ---- - '
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BUtL01NG ./ Ii!------ INSURANCE COVERAGE _
I hay abut • rance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 2 NO J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 171 JJ OTHER TYPE INDEMNITY _,J BOND IJ
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 ON : NER AGENT
SIGNATURE OF OWNER OR AGENT l/
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and -. • - of my kno�dge
and that all plumbing work and installations performed under the permit Issued for this application will be In compliance with • •rovislon of •
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNA I'E
MP'!J MGF D JP _J JGF J LPG'❑ CORPORATION(a# 3281C I PARTNERSHIPI,.,.t# I LLC J# I
COMPANY NAME E.F.Winslow Plumbing&Heating Co.,lnc. I ADDRESS 8 REARDON CIRCLE 1
CITY SOUTH YARMOUTH ' STATE', MA !ZIP 02664 ITEL.508-394-7778
FAX I CELLINIA (EMAIL accounts•a able r'efwinslow.com
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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 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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