HomeMy WebLinkAboutG-13-054 • ocr now,n , ons,
�. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�0' MA DATE 7 /I /Z ?PERMIT#4(Y
JOBSITE ADDRESS 7 -'/JF nase_AE {OWNER''SNAME _{3E,eTrpzt3DiA
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OWNER I Slime 1TEL 779_,�S/ dg38-1FAX T.
tin TYPE OR'
PST OCCUPANCY `
_TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL V-'
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CLEARLY NEW., RENOVATION:T !. REPLACEMENT , PLANS SUBMITTED: YES N0�.;
V APPLIANCES 1 FLOORS-. BSM 1 2 3 • 4 5 6 7 8 9 10 11 12 13 14
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BOILER 1, __ ..� ___ . v
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CONVERR i-1' J_fa �li=tl i % .E i"
\ DRYOERROVE BURNER _1i_i'�' _� __- i -mob [ IS
DIRECT VENT HEATER - •___J,
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FIREPLACE .l i_ _�i E t• t p x -n�r� :..
FRYOLATOR t, ^;ii,_._ f is i - Otille t uE L
FURNACE -_J`_N ._.i I•— f, $q— -
GENERATOR S I __ t 1-- f -'1-- t i,__
GRILLE - -` _.
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t INFRARED HEATER P___.11 • t
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LABORATORY COCKS I s - '
S MAKEUP AIR UNIT .— 4' _
OVEN J t __ r I..^ss
POOL HEATER __i
1, r - 1^ '_ L � r_ t� L
ROOF TOP UNIT £ --"
HEATERCk. ROOM/SPACE I
TEST
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UNIT HEATER h _I I I -i {I s+ . 1_
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UNVENTED ROOM HEATER _ i^r "� i i -
WATERHEATER 1 , - Jif V ', .� ` J
OTHER • G jj ,___1;__',1___J t_
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INSURANCE COVERAGE �`�r"" "
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES t4 NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY „L OTHER TYPE INDEMNITY ,D BOND Li
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 : , INLY: OW• R A , -_ -
SIGNATURE OF OWNER OR AGENT
I hereby certify that alt of the details and information I have submitted or entered regarding this application are true an. -. -:te to = best• owledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit• -II Pe ' - t. .0-on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Stephen A Winslow !LICENSE#'12298 SIGNATURE
MP ,,!J MGF --„J JP _ ) JGF'_J LPGI ,_ CORPORATION d# 32810 i PARTNERSHIP f#' - ^1 LLC '#
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COMPANY NAME E F. nslow Plumbing Heating Co,Inc. ;ADDRESS;8 Reardon Circle
CITY . South Yarmouth ____t STATE MA I ZIP i 02664 TEL 508-394-7778
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FAX;508-394-8256 J CELL N/A , 'EMAIL accountspa able efwlnslow.com