HomeMy WebLinkAboutG-12-750 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T FORM GAS FITTING WORK
gli_� CITY ylgg/Yl(JUT1l _. . - MA D TE ' 'fi. PE IT#C/Z' 750i' JOBSITEADDRESS'„/l /EA.4i9A-r OWNER'S NAME 6c Cas 4-
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<T OWNER ADDRESS ; t' C is C'/EosS/.'G TELLi
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TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL
PRINT RESIDENTIAL K1
CLEARLY NEW:j,,, i RENOVATION:-( REPLACEMENT:Li PLANS SUBMITTED: YES U NO ILI
v APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER „ 1 t I"` 'i^I I, It__ I !— -- ;
CONVERSION BURNER .'-7 ___ —_ ..— —j'' 1 -- I ---.c.._
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DRYER wait'DIRECT VENT HEAT - 11____-
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FuRNAGE � o• ! — w J
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INFRARED HEATER j�� � - " y
LABORATORY COC j r I _--e� ' -_.._--'r �
MAKEUP AIR UNIT m m if i _. t
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POOL HEATER j
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TEST 1a's1� �
UNIT HEATER )-
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UNVENTED ROOM HEATER ' I __ -'—I i_` l;---1 .______! "'-�
WATER HEATER t r _
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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 +j NO ,_.,I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY '-;J OTHER TYPE INDEMNITY J BOND Li
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 a IEONL r NE• 0 •
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this appy =ton are true an. rate to . e best of 'sledge
and that all plumbing work and Installations performed under the permit Issued for this application ill be in complian all P- i -nt provis •• of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME i Stephen A.Winslow ,I LICENSE it:12298 SIGNATURE
MP ..!..1 MGF J JP JGF Li LPG!I I CORPORATION'!(#73-2-81C -1 PARTNERSHIP:1#] LLC j#>
COMPANY NAME.F.Winslow Plumbing&Heating Co, Inc. J ADDRESS i 8 Reardon Circle i
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CITY South Yarmouth J STATE i MA.JZIP t02664 TEL508-394-7778 __I
FAX 508-394-8256 CELL N/A I
' [EMAIL accounts a able efwinslow.com
ROUGH GASASINSPECTION NOTES /�y� THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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flier Yes No / /� ,v 01 /mI IO
I THIS APPLICATION SERVES AS THE PERMIT
• FEE: S - PERMIT#
PLAN REVIEW NOTES
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