HomeMy WebLinkAboutG-14-019 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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,/ MA DATE?//04' 'PERMIT# levy 019
JOBSITE ADDRES 4122_, . _64/5 /VT &R'SNAME9ff2 _/ os !/nJ, j
G OWNER ADDRESS 0y (.t,,c6O g4IS LT,{E. 1 TEL j(2g 41O�p JFAX J
TYPE OR OCCUPANCY TYPE COMMERCIAL,Y l EDUCATIONAL J RESIDENTIAL Li
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' CLEARLY NEW:'j RENOVATION:D REPLACEMENT:LJ PLANS SUBMITTED: YES NOD
APPLIANCES 2 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER .
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
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DRYER
FIREPLACE
' FRYOLATOR I ..-_j .. .
FURNACE ='
GENERATOR
GRILLE
INFRARED HEATER _-. ..._-- i .-. .. . . ',_...
LABORATORY COCKS '
MAKEUP AIR UNIT
OVEN
POOL HEATER ,
ROOM I SPACE HEATER
ROOF TOP UNIT _-..'
TEST
UNIT HEATER
UNVENTED ROOM HEATER —_ _..:
WATER HEATER1 ' '
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INSURANCE COVERAGE
I have a current Jiability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Iii NO _J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L J OTHER TYPE INDEMNITY __I BOND f
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the f
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK 0, r 'LY: OWNER_1 AGENT J
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 a • ascur e to the ,est of my knowl•.c_
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance 'y:II Pertine t provision of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW I LICENSE# 12298 SIGNA RE -
MPJ MGF(,,,,I JP _,I JGF_J LPG'Li CORPORATION'J# 3281C l PARTNERSHIP_1# I LLC __;#1------1
COMPANY NAME: EF Winslow Plumbing&Heating Co Inc. _L ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH • _..J STATE 1 MA (ZIP 02664 ITEL 508-394-7778 )'
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FAX 508.394.8256 i CELL N/A I EMAIL accountspa able efwinslow con,
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