HomeMy WebLinkAboutG-13-525 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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rail= CITY Vngi/Ot 7f-1 soca-rA I MA DATE /1/2.942- J PERMIT# '6/./-- Or
fA JOBSITE ADDRESS 31 GLI069 5YIZ < OWNER'S NAME 16/4217(2 frac C a954rlf2
4 G OWNER ADDRESS _5/41-44 E.— TEL 97/.16 b)y'7IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL DI EDUCATIONAL❑ RESIDENTIAL Er
PRINT
CLEARLY NEW:❑ RENOVATION:ft REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER If 6 d . 11 ,_ , ' i
BOOSTER - r I I II I I- f I_
CONVERSION BURNER ..
COOK STOVE r
NM
DIRECT VENT HEATERI
DRYER 1I b
FIREPLACE I .
FRYOLATOR I— I Il—l
FURNACE h- I I' II
GENERATOR 0,-- Y N r A : r
GRILLE h _ N 1 I� •
INFRARED HEATER If l ^ ,� _ '. c" a
LABORATORY COCKS _ 1` f I #_ _I I' l
MAKEUP AIR UNIT I I I' 0r I II i'
OVEN POOL HEATER I I "L 11 Nil aililliie 1 i
ROOM I SPACE HEATER It f S 4 MaS 1
ROOF TOP UNIT II
TEST 111111 I Y I, 11111Ian i. . i
UNIT HEATER - I' I ll h
UNVENTED ROOM HEATER 1 I li I -_ I I I-
WATER HEATER _ T1 'r _ iI 1 1 . - Ti 1
OTHER i 'I r r-
I 1 r� t
I > . ' 4 I: Il' N II
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND ❑
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 J OW • 'a AGED
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 an r to th best of edge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance wi Pe :nt• ovis, of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Stephen A.Winslow LICENSE# 12298 I SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 3281C PARTNERSHIP 0# LLC❑#
COMPANY NAME: EF Winslow Plumbing&Heating Co.,Inc. ADDRESS 8 Reardon Circle
CITY South Yarmouth STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 CELL N/A EMAIL!accountspayablega efwinslow.com �D f C U - I
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