HomeMy WebLinkAboutG-12-444 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS�Rl1Sl1C.T7YeVe ' IOWNER'SNAME1,wjlljhYY1 I1aj'r\S ( 11
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OWNER ADDRESS ( I . .
TYPE OR ,
PRINT OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL' "
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:LW PLANS SUBMITTED: YES❑ NO
APPLIANCES 7 FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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CONVERSION BURNER L' _ J I – on si E _ ,
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BOOSTER N_ J moo „"t C l� ,I� I - _ I
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COOK STOVE 1 MINIIIIIIIIIII ��y' If
DIRECT VENT HEATER - '.�� I i
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FIREPLACE
FRYOLATOR �JJin allejl –{:
FURNACE SSIIIIIMMAISPIIIMMOISSISIIMMINISMNIS
GENERATOR .11SII MilI i— � +
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INFRARED HEATER SIIIIIIIIISSIIIIIMII001111111.11111101$11111111.1101111111$110111110111111111M
LABORATORY COCKS1MISISISSIEMINIONMESPIRIiMISIMUM
MAKEUP AIR
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POOL HEATER i J ��-J -a ,, ..f
POOL HEATER
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ROOM IS C 1 J I
ROOF UNIT f ,I JIIII , 1
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UNIT HEATER -. -- �� ��;
UNVENTED ROOM HEATER - Mita
WATER HEATER SWI J - _ 1 MIN
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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 0 NO U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - ; -
LIABILITY INSURANCE POUCY 0+ 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 r• •NLY: I I NE' ❑ AGENT r
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application a -true and a• urate tot :b, t of my • -
and that all plumbing work and Installations performed under the permit Issued for this application will be In com• - : :ith all Pert a pr. 'sion 7 I
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME STEPHEN A.WINSLOW (LICENSE f 1 SIGNATURE
MP[3 MGF❑ JPO JGF❑ LPGI❑ CORPORATION Q# 3281C ' PARTNERSHIP❑# LLC❑#F—! 1
COMPANY NAME: E.F.WINSLOW PLUMING&HEATING (ADDRESS 8 REARDON CIRCLE (
CITY SOUTH YARMOUTH I STATE MA ZIP 02664 TEL 508-394-7778
FAX 508-394-8256 (CELL NIA (EMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY _ FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: PERMIT# IC
PLAN REVIEW NOTES
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