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t _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"L_iCITY VRiRnwE MA DATES 6 Is--/Tai PERMIT#(i 12---740 3
JOBSITE ADDRESS; ���
A OWNER'S NAME I...“S"� 6
GOWNER ADDRESS i. c_ _____ , --_ ITEU _ FAX'—
N TYPE OR
OCCUPANCY TYPE COMMERCIAL;,) EDUCATIONAL r_-_,-1 RESIDENTIAL
CLEARLY NEW:;, RENOVATION: REPLACEMENT:FL] PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS-, BSM 1 2 3 • 4 5 6 7 8 9 10 11 12 13 14
BOILER ._i}I____J1 t1_1. ___1__} _____J'___ f•___J __L'—.. _a__._._. .,
BOOSTER
CONVERSION BURNER II__I I 1-ip-6;—;I� f—�I'.i^'�
._ t1__._.i_._f t- k_.�I _J -ft- ' _.
COOK STOVE ---I I—I� 1,1______.1 I J 1— L f�.� ,
._______.1'__A__AF____I_d I it .._I_.__,.I+—__I„._.11__.1, 1.___I____JI
DIRECT VENT HEATER _____I__.__S—;,___I__I _I_____1!. t i h_f _i;_ j d r _ ;
DRYER a 1 _i---J I. ...._ r i'--I i 1—' I
FIREPLACE Tom-'J • --_ —i —t I _ _I
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FRYOLATOR , . . WOMB �I —I -_._.E__f i ,—_ f —I_J_1'_.-1 i
FURNACE - ____,, Jam'"—_f—J —J1'—_I Jam'_I —_f—_f—1_--1, .
GENERATOR cw �i -_J— -_..I_J___-.I—.._J;___-_I — —
GRILLE .L_t co ire' ,�I�..I d ...- t II, t. E I 1 _ t ._
INFRARED HEATER L---bo c-' 0 1,. I. J ' ' �'
LABORATORY COCKS - 5 �:v _J i___I l = —1� [ II____I J I ,,
...._f!Ad
MAKEUP AIR UNIT t -.T` II
I -1_I i _
I Ir I I
OVEN r __h_—!i—_J —} 1 I _.:.____.1i�''.____I•II— I f i--1,____
POOL HEATER =
ROOM I SPACE HEATER _ _.. _.
ROOF TOP UNIT __LI—I iib_ , i t` 1 J I-__JI___.1 I I ___t_..__'
TEST Ih II I I 1 1 it _IIil l 1 - i____
UNIT HEATER II II J k,-1 t__I I 1, 1 i...1 til I: I
UNVENTED ROOM HEATER I 1'i II I I II____tfi11_11 _ ...
I I-—`' I 1 l s�
WATER HEATER I I—_ ._P h I I,_. 1 . _.,_II —__!1_ P.__ 1_,
OTHER I -_.._+ ___I ___�.__ J—t_—_I J+___ I. I _._..1 t i __
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. .___1 i___1' h .t---d_11_1_I i_____)._____.1 I ik I ._._I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 1
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY „+,-„I OTHER TYPE INDEMNITY J BOND 0
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 ' E ONLY: OWNE' D A AT D
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 -,• urate t• t = best i • y knowledge
and that all plumbing work and Installations performed under the permit Issued for this application II be in complian - ,-i r - I -- e - .ro-.ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME SteFe-n A.Winslow------H71 LICENSE#I7221-8 1 SIGNATURE
MP J2 MGF LI JP._J JGF r„] LPGI_J CORPORATION,`+J.#01.9_1P ARTNERSHIP L,J# 1 LLC I?:
COMPANY NAME:,E.F.Winslow Plumbing&Heating Co., Inc. 1 ADDRESS i 8 Reardon Circle
—.
CITY South Yarmouth STATE; MAZIP!02664 TEL 1508x394 7778
FAX 508-394-8256 CELL1 N/A '--- — `- --
EMAIL accounts a able efivinslow.crom I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: S PERMIT#
PLAN REVIEW NOTES