HomeMy WebLinkAboutG-12-682 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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GI® CITY ' / YYiO1J rki MA DATE; .� fA-1 PERMIT 40-- (.. 2-- `
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T JOBSITEADDRESS' as- S}/ eT -_ ._..
Q �,,�OWNER'SNAMEI_ _ ..._
G OWNER ADDRESS i -3.6- a/L F-T Sr JEW TEL7�/,3•13,7 7q JFAX`
PRINT OCCUPANCY TYPE COMMERCIAL;,, ••. EDUCATIONAL RESIDENTIAL/
CLEARLY .
NEW:
.,.,,,E RENOVATION:LI REPLACEMENT:X PLANS SUBMITTED: YES D NO LI
APPLIANCES 1 FLOORS-' BSM 1 2 3 • 4 5 6 7 8 9 10 11 12 13 14
INi__M . - r ��_I �- I�Yi�F�!®�J�F i111I
\ BOOSTER � � ,ice � -- ,
CONVERSION BURNER I����� '" _I II1 . - - til
COOK STOVE � JMi_L-_ ��SI Irl`-1 Ill
DIRECT VENT HEATERE. i II I l
DRYER --11411111---1_ - I -I _I
FIREPLACE I - ��1� 1M���
FRYOLATOR _gli 4 �: - �I 1 _.,
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FURNACE 1P4MSMIE J—1—i _J- __. . !
GENERATOR ��_ I __JIM � _ t y.
GRILLE i�l - t _ __.1
INFRAREDHEATER i _ -- I, --1 � -"'_r
LABORATORY COCKSmisoll__ :I I _-.-P
MAKEUP AIR UNIT I l }
OVEN
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POOL HEATER -• -
ROOM/SPACE HEATER
ROOF TOP UNIT -- Ci �I �s`TEST f� i -IEWIll
UNIT HEATER 1
UNVENTED ROOM HEATER --' 't - I
WATER HEATER _
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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 :NO ( I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 21 OTHER TYPE INDEMNITY ,,,) BOND D
OWNER'S INSURANCE WAIVER:l 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 K ONE ONLY: W' R AG ;. 3
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are •• I. - to to th= best of y k •wledge
and that all plumbing work and installations performed under the permit Issued for this appl• -tion will be In complian•: f all Pert! -n slop 4 the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - I
PLUMBER-GASFITTER NAME'Stephen A Winslow ' ��. LICENSE#' 122•• j; SIGNATURE
MP 4MGF
_._.E JP„- .
� JGF L.f LPG!LI; CORPORATION I4# 3281C � r
PARTNERSHIP,r,:1#! LLCI #1
COMPANY NAME. E.F.Winslow Plumbing&Hea6n Co Inc.j ADDRESS;8 Reardon Circle ;
-
CITY South Yarmouth I STATE MAJZIP:02664 ITEL1508-394-7778
FAX 5083948256 I CELL;N/A JEMAILIaccountspayablejaefwinslow.corn
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE $ PERMIT#
PLAN REVIEW NOTES
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