HomeMy WebLinkAboutG-12-572 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING]WORK
ulna, CITY f1Aon/UVt 1 MA DATEIn 'o& 121PERMITtag 2 ' S72
G JOBSITEADDRESS{5 t .M ue a1L.( IOWNER'S NAME�1t#k /N.0 .[ �
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t OWNER ADDRESS'I W rAh(�!h I TEL 77-17673-8119X
TYPE OR OCCUPANCY TYPE--- COMMERCIAL El EDUCATIONAL RESIDENTIAL&V, -
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CLEARLY . NEW:LI RENOVATION Q REPLACEMENT:E.I PLANS SUBMITTED. YES[ Nit /
BOILETERES 1 FLOORS-. BSM J 1 2 JI 3 4 5 6 1 7 'Y B I� 10 J 11� 12 J 13 J 14
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HEATER SC J
LABORATORY COCKS J j
MAKEUP AIR UNIT
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POOL HEATER ... . ._.._.. • :.. _ I I
ROOM/SPACE HEATER 1 P -__- I
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ROOF TOP UNIT H __
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UNVENTED ROOM HEATER Sjf �f
OTHER WATER HEATER I - J J5 _ J
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INSURANCE COVERAGE
I have a current Jiability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El • OTHER TYPE INDEMNITY ❑ 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 requirem
CHECK NE ONLY: t)WN R ❑ GENT /
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding Is application are true an ur a to the b=-t• my kn• -
and that all plumbing work and Installations performed under the permit issued for this app lion will be in compliance I ertine pr i-o •f -
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW LICENSE# 12298 SIGNATURE
MP El MGF❑ JP[] JGF❑ LPGI❑ CORPORATION LP 3281C PARTNERSHIP L]#j I LLC p# --
COMPANY NAME: E.F.WINSLOW PLUMING&HEATING ADDRESS 8 REARDON CIRCLE
CITY SOUTH YARMOUTH STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM 1
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