HomeMy WebLinkAboutG-13-797 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
E=_2h; CITY . ��`h .. . / MA.DATE ®2 .2'7- /3 I PERMIT# !7/3 -797
JOBSITE ADDRESS; 6.T (ciie/,PX _ (OWNER'S NAME ` / rine / 4lr 0e..4
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G OWNER ADDRESS "//2.4 n—ic /A11 •T7E- TEW V5 5 9711 FAX _ _�
TYPE OR OCCUPANCY TYPE COMMERCIAL, EDUCATIONAL I RESIDENTIAL
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NEW:_„( RENOVATION: _..1 REPLACEMENT: ,e PLANS SUBMITTED: YES_1 NOed—
'1/41 APPLIANCES 1 FLOORS-. 8SM 1 2 3 4 5 8 7 8 9 10 11 12 13 14
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FIREPLACE
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FURNACE all1.' 1 65''i5l�,5'SSlu_i
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INFRARED HEATER 11111.1.11,11111111A1,111111001111011millillislaimai5..5
LABORATORY COCKS a5111.11111911111115I1.11fi111■1f11.1111111111I11111111111•_IS_I_i
MAKEUP AIR UNIT 41111,11111110111.1SINUINIONIMmillgraapswimissions
OVEN X15515,._1Il 555
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POOL HEATER I � a"°"•d`
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lmilinsions 01111101 Me Illoppalmnpanamiwassa psi
UNIT HEATER camimiummmillfffl i5,Si S1SS'i ISia 1 s
UNVENTED ROOM HEATER SMINSINIMIIIISMIS
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WATER HEATER 1 I e line illtil cT�M
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�. ..._ — .r - INSURANCE COVERAGE •
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L'!NO -.i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY :!.1 OTHER TYPE INDEMNITY J • BOND I_J
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 ONLY: NER 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 a ra o the • st of my edge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with t p • ;Won . I a
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW . • . LICENSE# 12298. J . SIGNATURE
MP 'I MGF _.J JP JGF__; LPG' _ ; CORPORATION __I# 3281•_ i PARTNERSHIP J# ; ,J LLC .__I# _,_
COMPANY NAME E_F,WINSLOW PLUMBING&HEATING COJ ADDRESS•8 REARDON-CIRCLE •
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CITY SOUTH YARMOUTH ' STATE, MA. ,ZIP 02664_ . :TEL 508.394-7778 . _T _-, ..__
FAX.508.394.8256 CELL._•_, .,,,,,..__ , .!EMAIL ACCOUNTSPAYABLE@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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