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HomeMy WebLinkAboutG-12-753 ..._ata _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK LN_r, 144-`7. ICITY I m __„TJ MA DATE;—(4---‘4.11,1PERMIT#C/2- 753 _ N w II JOBSITEADDRESSIV S 7LLaa.//�Z_ 1OWNER'S NAME r j 1 r'r-/ OWNER ADDRESS [ Vwi/i, r i TEU /441 '7 1FAXI- - aP `I OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL, RESIDENTIAL. -' CLEARLY ' Td NEW:❑ RENOVATION:❑ REPLACEMENT:[)/ PLANS SUBMITTED: YES ] NOL&" . APPL#ANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Q BOILER I I BOOSTER CONVERSION BURNER SN 'I COOK STOVE ISM DIRECT VENT HEATER M, DRYER r'�=.LL' II, _ -- sue SIMI 11M1111 nri; iii iiiillpMe MKS Iii 11111111111 INFRARED HEATER. LABORATORY COCKS crvEKENUP AIR UNIT 111 III p C I •.. G I f ROOM I �. TESTP I UNIT HEATER - UNVENTED ROOM HEATER , WATER HEA ' e I I111111•111111111111111111111111113111111` ll li I I I l IF I J1 I I J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ll NO ._f I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 10 OTHER TYPE INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havq the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my Signature on this permit application waives this requirement. C ONE ONLY:. a NE' ;J AG A ' 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 c to to a •est of owledge end that all plumbing work and Installations performed under the permit Issued for this application will be In cornplianc all Pe. 0. ••• - of the Massachusetts State Plumbing Code end Chapter 142 of the General Laws. PLUMBER•GASFITTER NAME I STEPHEN A.WINSLOW (LICENSE SIGNATURE MPLa MGF 0 JP 0 JGF-j LPGI Li CORPORATION j j#(3281C J PARTNERSHIP U#: 1 LLC ,.I#f 1 COMPANY NAME:!E.F.WINSLOW PLUMING&HEATING I ADDRESSii REARDON CIRCLE CITY SOUTH YARMOUTH I STATE Fin ZIP[02664 —ITEL i 508-394-7778 I FAX 508.394.8256 CELLI NIA — IEMAII,ACCOUNTSPAYABLE©EFWINSLOW.COM — I: • ROUGasioTE S . • Man_ujsE ONLY __FiNAL INSPECTION NOTES c103 E YV•4 Yes No MS APpawsES AS THE Rmn• 0 0 ____________ FEES______PERMIT# ____ flAk map's= ---- -- I - • - I . I . . r 1 • I . . I . . I . H . I I , : I I ? I , . . • --- ---- -- - —