HomeMy WebLinkAboutG-12-616 4
r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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� OWNER ADDRESS �Sffjy�,� ,T/f��l� ,OW
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TYPE OR OCCUPANCY TYPE COMMERCIAL,-, EDUCATIONAL ' RESIDENTIAL,
PRINT- . ,
CLEARLY NEW: ,,_i RENOVATION) REPLACEMENT: i PLANS SUBMITTED:.YES,,,,, NO
APPLIANCES I FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 .. 14 .
-
• BOILER / •
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BOOSTER -- L lt7 !! i.5_. (,I
CONVERSION BURNER •
COOK STOVE ,L _._EPR 114 7111.Z. ...J
DIRECT VENT HEATER
DRYER •
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: _-- 13UIL0:N3OEPT
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT . •
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER , ..
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES f t`NO ,
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW-- ---l------.4-"
LIABILITY INSURANCE POLICY .., J OTHER TYPE INDEMNITY '_;: 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.
CHE ONE ONLY: 0 NER,_ , AG i
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 ur a to th- .>. of m. edge
and that all plumbing work and installations performed under the permit Issued for this appljjjeee. tion will be in compliance 't II Perti - .. .visi.r .f the
Ma4sachusetts State Plumbing Code and Chapter 142 of the General Laws. ' ( '
PLUMBER-GASFITTERNAME Stephen A Winslow* ;! LICENSE# 12298 ' SIGNATURE ,'
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MP .: MGF'„_ JP _ ; JGF. LPGI '_, ; CORPORATION, ,'# 3281C ' ` PARTNERSHIP-�,#; ! LLC ..# '
COMPANY NAME: E.F.Winslow Plumbing&Heating Co„ Inc, I ADDRESS 8 Reardon Circle
CITY South Yarmouth : STATE MA t ZIP 02664 TEL 508-394 7778
FAX.508 394.8256 ' CELL N/A EMAIL accountspayable@efwinslow.com .-,.
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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