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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
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;1-.1.1-7? ' CITY rc r 'tInYtt' S1R-1 I MA DATE r,Fp71- 71119 PERMIT#6 ' G
JOBSITEADDRESS['i'II I 441,1E• 1OWNER'S NAMEir.;I,,— 1\nfl 'Q,tcl I
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'-!L. OINNERADDRESS I _..—•--- ----- -ITE 7•17-�1FAXI
•1YPPRINT EOR OCCUPANCY TYPE` COMMEACIAL0 EDUCATIONAL 0' RESIDENTIAL[
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CLEARLY NEW:Q RENOVATION:❑
REPLACEMENT:ad PLANS SUBMITTED: YESLJ NOD
•` APPLIANCES 1 FLOORS-. SSM 1 2 3 4 5 8 7W J.
8 9 10 1 11 12 J 13 14
BOILER I' _ J.
BOOSTER
CONVERSION BURNER � f >�
COOK STOVE 1�•4�I � � M
DIRECT VENT HEATER0. � - �.
FRYER
RLA
FRYOLATOR
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FURNACE • ���i'iaIrp1ss asaisse
GENERATOR
GRILLE I. I k 1 i
INFRARED HEATER I I
. LABORATORY COCKS
'MAKEUP AIR UNIT 11
I 1
OVEN
POOL HEATER
ROOMISPACEHEATER I I I
ROOF TOP UNIT
TEST - II
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER ___--_ NMI MI MN OTHER ._._._,......---- r --... no
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INSURANCE COVERAGE
I have a current)labilipt Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LINO J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
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 require i •
C . KONEONLY:. 0 E• ;J A
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of Me details and Information I have submitted or entered regarding this application are true -•�I to to bast of • edge
and that as plumbing work and Installations performed under the permit Issued for this application will be In compliance 'l' Ii Pe t• • y of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER.GASFITTER NAME I STEPHEN A.WINSLOW I LICENSE# 9: SIG RE
MP Q MGF LJ JP Li JGF LPGI(Q . CORPORATION IJ#[i 81C I PARTNERSHIP..j# — 1 LLC:Yr- _ I
COMPANY NAME4 E.F.WINSLOW PLUMING&HEATING I ADDRESS 18 REAROON CIRCLE _
CITY SOUTH 02664--
YARMOUTH I STATE MA ZIP —ITEL I508.394T/78 I
FAX 508394-8256 CELLI N/A IEMAIL ACCOUNTSPAYABLE@EFWINSLOW.COM 1
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