G-13-116 �%e .12).•rMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Mina.
"illigric7 CITY f1 u1/ _ k MA DATE 16- %g-:J PERMIT# F14 /9&
�j/JOBSITEADDRESS` // 7 , 64LJ4/14) IOWNER'S NAME •,Ao-tG7/f0/ ,6'7 L.J 1
G OWNER ADDRESS 1 Y '
-
OCCUPANCY TYPE �''YCOMMERCIAL Li EDUCATIONAL Y�"11�Sjh/�Q�-�___ t k TEL�2y��7�O/�L.� FAX —�
TYPE OR _] RESIDENTIAL
PRINT /
CLEARLY NEW:j RENOVATION: .J REPLACEMENT:,a PLANS SUBMITTED: YES_I NOa r I`
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
1 BOILER I
1 t I1e,f7_
JII
am'"
GRILLE QIP n
INFRARED HEATER I I E OM
LABORATORY COCKS _il 1 .- _ _I
MAKEUP AIR UNIT 1 J .-_ J _q J
OVEN _ J I I -._�. J.... J
POOL HEATER _ ,._ _J_____I I 1
J 1 J J 1 ._.,
ROOM/SPACE HEATER '
ROOF TOP UNIT
TEST
UNIT HEATER ERS 1_ . I. S
UNVENTED ROOM HEATER in � � �J� - I _ - .111
WATER HEATER J 1_._-1 _J J ___1 __I__ _.1 _ . ._1 __ 1 _._ 1 .._,1
OTHER I __. _1 r J J._. .___ 1, __J . _J .. ..J .__l . __J ._.._1_ _J' _._.J J
• _..J ___ ___J __.__J__ _1,-_ I ___J ___._I_ 1 _I __I J ___._J_._J .._.. J ._ _..J
_ J _._ J _._1 t'_ -_J _ J 1 . _ _ J .J
J __
JJ _ T
'. _ __J_..._J ___1'_____I _.J_ _I _._J'_..__._1__ I _ 1 ....__J . _.J .__J .... ...J J
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Li NO ._.I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I;4J OTHER TYPE INDEMNITY .J BOND IJ
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: OWNER J AG • 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 and : cur. /o th- best of owledge
and that all plumbing work and installations performed under the permit Issued for this application will be In compliance wit al -:ni.:nt •r.vis r of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A WINSLOW 1 LICENSE# 12298_ — SIGNATURE
MP .J MGF _j JP JGF_J LPG! __j CORPORATION:J# 3281 j PARTNERSHIP #_________j LLC ._J#_._-
COMPANY NAME: E.F.WINSLOW PLUMBING&HEATING CO1 ADDRESS 8 REARDON CIRCLE .
CITY SOUTH YARMOUTH r _ STATE MA i ZIP 02664 __ 'TEL 508-394.7778 I
FAX 508.394.8256 I CELL IEMAIL ACCOUNTSPAYABLE@EFWINSLOW_COM
. v
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMR ❑ 0
FEE: S PERMIT
PLAN REVIEW NOTES
•
r