HomeMy WebLinkAboutG-12-736 • .1Z, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS' 77 2T 2& OWNER'S NAME r Et,ns1‹,/94-,01/5
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G OWNER ADDRESS i'Jr THee,Ni3/iie}/jPd, to/yemisri?01A]TEL Sob-3&S.5 7VgIFAX,-- I
TYPE OR CV 29.0
OCCUPANCY TYPE COMMERCIAL', EDUCATIONAL RESIDENTIAL J
CLEARLY NEW:!,-,1 RENOVATION:] REPLACEMENT:V.1 PLANS SUBMITTED: YES;,,, NO;-,}
ciAPPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
� BOILER ComT�a _ J`-_f'. ,-.--. --_I-1'-J._.-.J -.._ ._ .
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DIRECT VENT HEATER
DRYER sr is( =
FIREPLACE
FRY• •• I 1r
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GENERATOR t
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MAKEUP AIR UNIT ____y___ JI__ yaw -•
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ROOF TOP UNIT i — I -- Main 1
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WATER HEATER 44
OTHER i.
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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 LI NO jU
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I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
` LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY iQ BOND Li
V 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.
CH ONE ONLY: OWNE• 7,; AG
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 ccurate the -es of .•wledge
and that all plumbing work and Installations performed under the permit issued for this application will be in compliance wi II ertin: t.;•vi. • .f the
ac Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , -
PLUMBER•GASFITTERNAME S _ ._.-_.__._._' ._
Stephen A Winslow m l LICENSE#(1\1228 I SIGNATURE
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MP + MGF J JP JGF i LPGI } CORPORATION +'#i 3281C I PARTNERSHIP —,#? R LLC r j# i
COMPANY NAME.;E.F.Winslow Plumbing&HeaTting.Co., Inc. 1 ADDRESS;8 Reardon Circle
CITY South Yarmouth } STATE Si ZIP I 02664 ,TEL 1508-3947778
FAX 508-394-8256 I CELLI N/A _ EMAILI accounts able efwinslow.trom
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w ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
gbh" 6,55 On' Z-se/f- Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES