HomeMy WebLinkAboutG-14-408 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS. 203 ((7i g h 6(1 duo At z I OWNER'S NAME ajoi( 0 ,U/yv/ - Rr- .. +- S
GOWNER ADDRESS ; Ya 1'mi11911 0 ITEL S'DM. al6ggfliFAX _j
TYPE OR OCCUPANCY TYPE COMMERCIAL, EDUCATIONAL J RESIDENTIAb..Q '
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CLEARLY NEW:J RENOVATION:'_ REPLACEMENT: t PLANS SUBMITTED: YES J NO y'
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 61. 7 8 9 10 11 12 13 I/` 14
lc)\1 BOOSTER '._ 1 j �Q—J1�J h J' � — J _-J
'1.. CONVERSION BURNER i J' "___`_ - , —1
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DIRECT VENT HEATER �1' I� i J •I_ J I J 1
LiDRYER _J I 1 J J __I _.J ...i. 1 --iI—J ___.I _.
FIREPLACE ____1 ''___ J __I __._J___J ___l__ I__J_•.. J _.i
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POOL HEAT= y (' ' r _ _
ROOM I SPA &KATE a f 1
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UNIT HEATER Ina SSl1SJ� ' S011
UNVENTED ROOM HEATER MIEMMEMNIIMISMINEMISM. 1llIMINOM5--- -
WATER HEATER J S _I J +— __._I 1__ ____J _i _
OTHER I _ _ 1 _ 1 --_ ___J _I J - ' -__ . - J
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES Lii NO ._..i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY :+I OTHER TYPE INDEMNITY ,U BOND L.-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. -
CHECK ON, ONLY: 'WNER _J AG J'_i
SIGNATURE OF OWNER OR AGENT l fJ/
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a • •:te tot - best of nowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance 1 :1 Pe ' e t provis'•-• of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW ; LICENSE# 12298__J SIGNATURE
MP .!1 MGF —I JP. JGF__ LPGI'__, CORPORATION _ 1# 3281 PARTNERSHIP _I#__ _ J LLC _J# __ '
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING CV ADDRESS 8 REARDON CIRCLE _ , -_ ____
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394.7778___ ____.-„ _
FAX 508-394.8256 _i CELL__ , __ _ IEMAIL ACCOUNTSPAYABLEd@EFWINSLOW.COM
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
FLAN REVIEW NOTES