HomeMy WebLinkAboutG-13-409 MASSACHUSETTS� UNIFORM FOR A PERMIT TO PERFORM GAS FITTING WORK
kw41E CITY INT/L/ri0tL71-1 l� '� 1 , MA DATE / //Q`/Y 1PERMIT
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94 JOBSITEADDRESS 'J "MUM 4/L) n
LADE— (OWNER'S L,&Lis Sim0s J
7 G OWNER ADDRESS 54-/1/i..— (TEL col',525! 26 V(FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ID RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:CI REPLACEMENT:1 1 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
BOOSTER
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CONVERSION BURNER
COOK STOVE � I
DDIRECT RYER VENT HEATER 1
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FIREPLACE s _, _.,
FURN CEOR an
5 1- I�� II�IAgR - I
GENERATOR 0, 1� rSS
GRILLE I
INFRARED HEATERa , n
LABORATORY COCKS
No n
OVENUP AIR UNITSenna a
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POOL HEATER inert_ _
ROOM ISPACE HEATER 1 1 I 1
ROOF TOP UNIT I f r1 I' i
TEST I r I
UNIT HEATER r 1 i II
UNVENTED ROOM HEATER I� I' i
WATER HEATER ll1.1 I�■■ l �I�11C11 1iIari�ter ,MA1�G1�9Nr� �i�'4iiiq11■Ia�
OTHER � ,1 „—ItS ' ,ZMf pfg teCalln
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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 Q NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY C] OTHER TYPE INDEMNITY ❑ BOND ❑
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 0' ONLY: OW R * AG T IA
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 and acc rte tot : best of m,k -- edge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance r a -e ' e p •7i si• the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME STEPHAN A.WINSLOW I LICENSE# 12t:: sr SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 3281 C PARTNERSHIP❑# LLC❑#
COMPANY NAME: EF WINSLOW PLUMBING&HEATING I ADDRESS 8 REARDON CIRCLE (
CITY SOUTH YARMOUTH ( STATE MA ZIP 02664 TEL 508-394-7778 (
FAX 508-394-8256 CELL E IL[t`••sntrea b1J@gfwin$,riv.com (
11:0V 15 201 U efit1877fi F5-0- Fit? _ /C-
BUILDING DEPT
By
ROUGH GAS INSPECTION NOTES THIS PACE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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